Critical Illness Factors Associated With Long-Term Mortality and Health-Related Quality of Life Morbidity Following Community-Acquired Pediatric Septic Shock

Abstract

Objectives: A companion article reports the trajectory of long-term mortality and significant health-related quality of life disability among children encountering septic shock. In this article, the investigators examine critical illness factors associated with these adverse outcomes.

Design: Prospective, cohort-outcome study, conducted 2013-2017.

Setting: Twelve United States academic PICUs.

Patients: Critically ill children, 1 month to 18 years, with community-acquired septic shock requiring vasoactive-inotropic support.

Interventions: Illness severity, organ dysfunction, and resource utilization data were collected during PICU admission. Change from baseline health-related quality of life at the month 3 follow-up was assessed by parent proxy-report employing the Pediatric Quality of Life Inventory or the Stein-Jessop Functional Status Scale.

Measurements and main results: In univariable modeling, critical illness variables associated with death and/or persistent, serious health-related quality of life deterioration were candidates for multivariable modeling using Bayesian information criterion. The most clinically relevant multivariable models were selected among models with near-optimal statistical fit. Three months following septic shock, 346 of 389 subjects (88.9%) were alive and 43 of 389 had died (11.1%); 203 of 389 (52.2%) had completed paired health-related quality of life surveys. Pediatric Risk of Mortality, cumulative Pediatric Logistic Organ Dysfunction scores, PICU and hospital durations of stay, maximum and cumulative vasoactive-inotropic scores, duration of mechanical ventilation, need for renal replacement therapy, extracorporeal life support or cardiopulmonary resuscitation, and appearance of pathologic neurologic signs were associated with adverse outcomes in univariable models. In multivariable regression analysis (odds ratio [95% CI]), summation of daily Pediatric Logistic Organ Dysfunction scores, 1.01/per point (1.01-1.02), p < 0.001; highest vasoactive-inotropic score, 1.02/per point (1.00-1.04), p = 0.003; and any acute pathologic neurologic sign/event, 5.04 (2.15-12.01), p < 0.001 were independently associated with death or persistent, serious deterioration of health-related quality of life at month 3.

Conclusions and relevance: Biologically plausible factors related to sepsis-associated critical illness organ dysfunction and its treatment were associated with poor outcomes at month 3 follow-up among children encountering septic shock.

Figure 1.

Detailed flow diagram for the cohort. Abbreviations: HRQL, health-related quality of life; PedsQLTM, Pediatric Quality of Life Inventory; FSII-R, Stein-Jessop Functional Status Scale; N, total number of patients with available, adequate, change from baseline survey data at a particular time point; CFB, change from baseline; PSD-HRQL, persistent, severe deterioration of HRQL below baseline, specifically, HRQL scores (PedsQLTM or FSII-R) persisting > 25% below the baseline HRQL assessment at follow-up; D, cumulative deaths among the entire LAPSE clinical cohort (n=389). Seven of the 35 patients who died in the hospital did so after the Day 28 study time point. Two subjects where discharged from the hospital alive before Day 28, but died later during the Day 28 time point interval; ΣPSD-HRQL, total patients with persistent, severe deterioration of HRQL below baseline from PedsQLTM or FSII-R cohorts. 1 No clinical data was available due to early family-initiated withdrawal from the study or refusal to complete HRQL surveys. 2 Families never initiated a survey, even the baseline survey, or surveys were inadequately completed and could not be used for analysis.