Sociodemographic Factors are Associated with Care Delivery and Outcomes in Pediatric Severe Sepsis.

IMPORTANCE: Sepsis is a leading cause of morbidity and mortality in the United States and disparate outcomes exist between racial/ethnic groups despite improvements in sepsis management. These observed differences are often related to social determinants of health (SDoH). Little is known about the role of SDoH on outcomes in pediatric sepsis. OBJECTIVE: This study examined the differences in care delivery and outcomes in children with severe sepsis based on race/ethnicity and neighborhood context (as measured by the social vulnerability index). DESIGN SETTING AND PARTICIPANTS: This retrospective, cross-sectional study was completed in a quaternary care children's hospital. Patients 18 years old or younger who were admitted between May 1, 2018, and February 28, 2022, met the improving pediatric sepsis outcomes (IPSO) collaborative definition for severe sepsis. Composite measures of social vulnerability, care delivery, and clinical outcomes were stratified by race/ethnicity. MAIN OUTCOMES AND MEASURES: The primary outcome of interest was admission to the PICU. Secondary outcomes were sepsis recognition and early goal-directed therapy (EGDT). RESULTS: A total of 967 children met the criteria for IPSO-defined severe sepsis, of whom 53.4% were White/non-Hispanic. Nearly half of the cohort (48.7%) required PICU admission. There was no difference in illness severity at PICU admission by race (1.01 vs. 1.1, p = 0.18). Non-White race/Hispanic ethnicity was independently associated with PICU admission (odds ratio [OR] 1.35 [1.01-1.8], p = 0.04). Although social vulnerability was not independently associated with PICU admission (OR 0.95 [0.59-1.53], p = 0.83), non-White children were significantly more likely to reside in vulnerable neighborhoods (0.66 vs. 0.38, p < 0.001). Non-White race was associated with lower sepsis recognition (87.8% vs. 93.6%, p = 0.002) and less EGDT compliance (35.7% vs. 42.8%, p = 0.024). CONCLUSIONS AND RELEVANCE: Non-White race/ethnicity was independently associated with PICU admission. Differences in care delivery were also identified. Prospective studies are needed to further investigate these findings.

Cardiac dysfunction in severe pediatric acute respiratory distress syndrome: the right ventricle in search of the right therapy.

Severe acute respiratory distress syndrome in children, or PARDS, carries a high risk of morbidity and mortality that is not fully explained by PARDS severity alone. Right ventricular (RV) dysfunction can be an insidious and often under-recognized complication of severe PARDS that may contribute to its untoward outcomes. Indeed, recent evidence suggest significantly worse outcomes in children who develop RV failure in their course of PARDS. However, in this narrative review, we highlight the dearth of evidence regarding the incidence of and risk factors for PARDS-associated RV dysfunction. While we wish to draw attention to the absence of available evidence that would inform recommendations around surveillance and treatment of RV dysfunction during severe PARDS, we leverage available evidence to glean insights into potentially helpful surveillance strategies and therapeutic approaches.

Predicting High-Flow Nasal Cannula Therapy Outcomes Using the ROX-HR Index in the Pediatric ICU.

BACKGROUND: High-flow nasal cannula (HFNC) use is increasing in pediatric patients. Objective measures that predict HFNC outcomes are lacking. The respiratory rate-oxygenation (ROX) and ROX heart rate (ROX-HR) indices are validated to predict HFNC therapy failure in adults. This study examined the performance of both indices in predicting HFNC therapy failure in children admitted to the pediatric ICU (PICU). METHODS: This retrospective, longitudinal, observational cohort study was completed in a 24-bed PICU in a quaternary care children's hospital. All subjects ≤ 24 months of age initiated on HFNC in the PICU from January 1, 2018-August 31, 2020, were included. The ROX and ROX-HR indices were collected at standardized time points during HFNC therapy. Performance in predicting HFNC failure was evaluated using area under the receiver operating characteristic curve (AUROC) and Kaplan-Meier survival analysis. Failure was defined as escalation of respiratory support to either noninvasive ventilation or endotracheal intubation. RESULTS: Among 446 subject encounters, 111 (24.9%) failed HFNC therapy. HFNC failure was associated with lower ROX and ROX-HR indices at termination compared to HFNC liberation (P < .001). A ROX-HR index < 3 was significantly associated with a higher risk of HFNC failure at 1 (AUROC 0.76, P = .01) and 6 (AUROC 0.81, P = .02) h. CONCLUSIONS: ROX-HR may be a useful tool for early identification of patients ≤ 24 months at risk for HFNC failure and allow for earlier intervention. Larger prospective studies are necessary to validate the utility of the ROX-HR index in pediatric patients.