Cardiac dysfunction and ferritin as early markers of severity in pediatric sepsis<sup>,</sup>

Tonial, Cristian T.; Garcia, Pedro Celiny R.; Schweitzer, Louise Cardoso; Costa, Caroline A.D.; Bruno, Francisco; Fiori, Humberto H.; Einloft, Paulo R.; Garcia, Ricardo Branco; Piva, Jefferson Pedro

doi:10.1016/j.jped.2016.08.006

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Original articles • J. Pediatr. (Rio J.) 93 (3) • May-Jun 2017 • https://doi.org/10.1016/j.jped.2016.08.006 copy

Cardiac dysfunction and ferritin as early markers of severity in pediatric sepsis^☆ ☆ Please cite this article as: Tonial CT, Garcia PC, Schweitzer LC, Costa CA, Bruno F, Fiori HH, et al. Cardiac dysfunction and ferritin as early markers of severity in pediatric sepsis. J Pediatr (Rio J). 2017;93:301-7. ^,^☆☆ ☆☆ Study carried out at Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Postgraduate Program in Pediatrics and Child Health, Porto Alegre, RS, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

The aim of this study was to verify the association of echocardiogram, ferritin, C-reactive protein, and leukocyte count with unfavorable outcomes in pediatric sepsis.

Methods:

A prospective cohort study was carried out from March to December 2014, with pediatric critical care patients aged between 28 days and 18 years. Inclusion criteria were diagnosis of sepsis, need for mechanical ventilation for more than 48 h, and vasoactive drugs. Serum levels of C-reactive protein, ferritin, and leukocyte count were collected on the first day (D0), 24 h (D1), and 72 h (D3) after recruitment. Patients underwent transthoracic echocardiography to determine the ejection fraction of the left ventricle on D1 and D3. The outcomes measured were length of hospital stay and in the pediatric intensive care unit, mechanical ventilation duration, free hours of VM, duration of use of inotropic agents, maximum inotropic score, and mortality.

Results:

Twenty patients completed the study. Patients with elevated ferritin levels on D0 had also fewer ventilator-free hours (p = 0.046) and higher maximum inotropic score (p = 0.009). Patients with cardiac dysfunction by echocardiogram on D1 had longer hospital stay (p = 0.047), pediatric intensive care unit stay (p = 0.020), duration of mechanical ventilation (p = 0.011), maximum inotropic score (p = 0.001), and fewer ventilator-free hours (p = 0.020).

Conclusion:

Cardiac dysfunction by echocardiography and serum ferritin value was significantly associated with unfavorable outcomes in pediatric patients with sepsis.

KEYWORDS
Sepsis; Septic shock; Echocardiogram; Outcome; Pediatric intensive care unit

Patient characteristics	Data at recruitment (D0)
Age (m) M, SD	6 ± 3
Weight (g) M, SD	7383 ± 2471
Male gender n, %	12 (60)

Predominant dysfunction at PICU admission
1. Respiratory n, %	11 (55)
2. Cardiocirculatory n, %	6 (30)
3. Neurological n, %	3 (15)

External patient n, %	17 (85)
Time of MV before recruitment (h) M, SD	63 ± 19
Time of inotropics before recruitment (h) M, SD	55 ± 13
Inotropic score at D0 M, SD	33 ± 39
PIM2% M, SD	13.7 ± 15.7
PIM2 > 6% n, %	12 (60)
Leukocytes/µL M, SD	14,852 ± 5663
CRP mg/dL M, SD	12.6 ± 9.7
Ferritin ng/mL MDN, IQR	172 (118.3-514)
Ferritin ≥300 ng/mL n, %	8 (40)

	With cardiac dysfunction EF < 55% n = 6	Without cardiac dysfunction EF ≥55% n = 14	p
Length of hospitalization (days)^a a Values expressed as mean and standard deviation.	40.7 ± 28.8	23.3 ± 8.3	0.047
Time of hospitalization at PICU (days)^a a Values expressed as mean and standard deviation.	33.7 ± 26.8	14.9 ± 6.0	0.020
Total MV time (h)^a a Values expressed as mean and standard deviation.	799.3 ± 644.5	293.4 ± 152.6	0.011
Ventilation-free hours (h)^b b Values expressed as median and interquartile range.	0 (0-144)	373.50 (316.30-511.30)	0.020
Total inotropic time (h)^a a Values expressed as mean and standard deviation.	370.3 ± 255.4	262.7 ± 137.2	0.231
Maximum inotropic score^a a Values expressed as mean and standard deviation.	134.2 ± 92	28.5 ± 22.6	0.001
PIM2%^a a Values expressed as mean and standard deviation.	33.9 ± 13.9	5.0 ± 4.1	<0.001
PIM2 >6% n, %	6 (100%)	0 (0%)	-
Deaths n, %	2 (33%)	0 (0%)	-

	Day zero	Day 1	Day 3	p
Ferritin, ng/mL^a a Values expressed as median and interquartile range.	172 (118.3-514.0)^c c,d,e The same letter indicates no difference between the groups. Normality was verified by the Kolmogorov-Smirnov test. CRP, C-reactive protein.	173.9 (109.8-617)^c c,d,e The same letter indicates no difference between the groups. Normality was verified by the Kolmogorov-Smirnov test. CRP, C-reactive protein.	158.9 (77.8-361.9)^c c,d,e The same letter indicates no difference between the groups. Normality was verified by the Kolmogorov-Smirnov test. CRP, C-reactive protein.	0.939
CRP, mg/dL^b b Values expressed as mean and standard deviation.	12.6 ± 9.7^c c,d,e The same letter indicates no difference between the groups. Normality was verified by the Kolmogorov-Smirnov test. CRP, C-reactive protein.	8.8 ± 6.5^d c,d,e The same letter indicates no difference between the groups. Normality was verified by the Kolmogorov-Smirnov test. CRP, C-reactive protein.	3.5 ± 1.8^e c,d,e The same letter indicates no difference between the groups. Normality was verified by the Kolmogorov-Smirnov test. CRP, C-reactive protein.	<0.001
Leukocytes/µL^b b Values expressed as mean and standard deviation.	14,852 ± 5663^c c,d,e The same letter indicates no difference between the groups. Normality was verified by the Kolmogorov-Smirnov test. CRP, C-reactive protein.	16,874 ± 9599^c c,d,e The same letter indicates no difference between the groups. Normality was verified by the Kolmogorov-Smirnov test. CRP, C-reactive protein.	15,672 ± 6197^c c,d,e The same letter indicates no difference between the groups. Normality was verified by the Kolmogorov-Smirnov test. CRP, C-reactive protein.	0.684

	Ferritin ≥300 ng/mL n = 8	Ferritin <300 ng/mL n = 12	p
Length of hospitalization (days)^a a Values expressed as mean and standard deviation.	35.5 ± 26.4	23.8 ± 8.4	0.166
Time of hospitalization at PICU (days)^a a Values expressed as mean and standard deviation.	28.6 ± 24.7	15.1 ± 6.1	0.084
Total MV time (h)^a a Values expressed as mean and standard deviation.	664.0 ± 604.1	299.3 ± 154.1	0.058
Ventilation-free hours (h)^a a Values expressed as mean and standard deviation.	175.5 ± 258.2	372.6 ± 157.1	0.046
Total inotropic time (h)^a a Values expressed as mean and standard deviation.	322.3 ± 240.3	276.8 ± 136.7	0.594
Maximum inotropic score^a a Values expressed as mean and standard deviation.	108.6 ± 92.2	27.9 ± 23.1	0.009
PIM2 (%)^a a Values expressed as mean and standard deviation.	28.5 ± 15.5	3.8 ± 3.0	<0.001
PIM2 >6% n, %	8 (100)	4 (33.3)	0.001
Deaths n, %	2 (25)	0 (0)	-

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[1] * Corresponding author. E-mail:cristiantonial@gmail.com (C.T. Tonial).