美国华盛顿大学R. Scott Watson团队开发出了儿童脓毒症和感染性休克的国际共识标准。该研究于2024年1月21日发表在《美国医学会杂志》上。

脓毒症是全世界儿童死亡的主要原因。根据专家意见，目前脓毒症的儿科特异性标准于2005年发表。2016年，《脓毒症和脓毒症休克第三国际共识定义》（Sepsis-3）将脓毒症定义为宿主对感染反应失调导致的危及生命的器官功能障碍，但不包括儿童。该研究旨在更新和评价儿童脓毒症和感染性休克的诊断标准。

重症监护医学学会（SCCM）召集了一个由来自6大洲的35名儿科专家组成的工作组，他们分别从事重症监护、急诊医学、传染病、普通儿科、护理、公共卫生和新生儿科。利用国际调查、系统综述和荟萃分析的证据，以及基于来自4大洲10个机构的300多万份电子健康记录制定的新型器官功能障碍评分，采用改进的德尔菲共识过程来制定标准。

根据调查数据，大多数儿科临床医生使用脓毒症来指代具有危及生命的器官功能障碍的感染，这与之前使用全身炎症反应综合征（SIRS）标准的儿科脓毒症标准不同，后者具有较差的预测特性，并包括冗余术语“严重脓毒症”。SCCM特别工作组建议，通过疑似感染儿童的Phoenix脓毒症评分至少为2分来确定儿童脓毒症，这表明呼吸、心血管、凝血和/或神经系统可能存在危及生命的功能障碍。Phoenix败血症评分至少为2分的儿童在较高资源环境中的住院死亡率为7.1%，在较低资源环境中为28.5%，是不符合这些标准的疑似感染儿童的8倍多。

非主要感染部位的四类器官系统（呼吸、心血管、凝血和/或神经系统）中至少有1类器官功能障碍的儿童死亡率更高。脓毒症休克被定义为患有脓毒症的儿童，其心血管功能障碍由Phoenix脓毒症评分中至少1个心血管点指标，包括年龄严重低血压、血乳酸超过5 mmol/L或需要血管活性药物。在资源较高和资源较低的环境中，感染性休克儿童的住院死亡率分别为10.8%和33.5%。

综上，国际SCCM儿科脓毒症定义工作组使用大型国际数据库和调查、系统综述和荟萃分析以及改进的德尔菲共识方法，推导并验证了儿童脓毒症和脓毒症休克的Phoenix脓毒症标准。Phoenix败血症评分至少为2可确定18岁以下感染儿童可能危及生命的器官功能障碍，其使用有可能改善世界各地儿童败血症和感染性休克的临床护理、流行病学评估和研究。

附：英文原文

Title: International Consensus Criteria for Pediatric Sepsis and Septic Shock

Author: Luregn J. Schlapbach, R. Scott Watson, Lauren R. Sorce, Andrew C. Argent, Kusum Menon, Mark W. Hall, Samuel Akech, David J. Albers, Elizabeth R. Alpern, Fran Balamuth, Melania Bembea, Paolo Biban, Enitan D. Carrol, Kathleen Chiotos, Mohammod Jobayer Chisti, Peter E. DeWitt, Idris Evans, Cláudio Flauzino de Oliveira, Christopher M. Horvat, David Inwald, Paul Ishimine, Juan Camilo Jaramillo-Bustamante, Michael Levin, Rakesh Lodha, Blake Martin, Simon Nadel, Satoshi Nakagawa, Mark J. Peters, Adrienne G. Randolph, Suchitra Ranjit, Margaret N. Rebull, Seth Russell, Halden F. Scott, Daniela Carla de Souza, Pierre Tissieres, Scott L. Weiss, Matthew O. Wiens, James L. Wynn, Niranjan Kissoon, Jerry J. Zimmerman, L. Nelson Sanchez-Pinto, Tellen D. Bennett, Society of Critical Care Medicine Pediatric Sepsis Definition Task Force, Juliane Bubeck Wardenburg

Issue&Volume: 2024-01-21

Abstract:

Importance  Sepsis is a leading cause of death among children worldwide. Current pediatric-specific criteria for sepsis were published in 2005 based on expert opinion. In 2016, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defined sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, but it excluded children.

Objective  To update and evaluate criteria for sepsis and septic shock in children.

Evidence Review  The Society of Critical Care Medicine (SCCM) convened a task force of 35 pediatric experts in critical care, emergency medicine, infectious diseases, general pediatrics, nursing, public health, and neonatology from 6 continents. Using evidence from an international survey, systematic review and meta-analysis, and a new organ dysfunction score developed based on more than 3 million electronic health record encounters from 10 sites on 4 continents, a modified Delphi consensus process was employed to develop criteria.

Findings  Based on survey data, most pediatric clinicians used sepsis to refer to infection with life-threatening organ dysfunction, which differed from prior pediatric sepsis criteria that used systemic inflammatory response syndrome (SIRS) criteria, which have poor predictive properties, and included the redundant term, severe sepsis. The SCCM task force recommends that sepsis in children be identified by a Phoenix Sepsis Score of at least 2 points in children with suspected infection, which indicates potentially life-threatening dysfunction of the respiratory, cardiovascular, coagulation, and/or neurological systems. Children with a Phoenix Sepsis Score of at least 2 points had in-hospital mortality of 7.1% in higher-resource settings and 28.5% in lower-resource settings, more than 8 times that of children with suspected infection not meeting these criteria. Mortality was higher in children who had organ dysfunction in at least 1 of 4—respiratory, cardiovascular, coagulation, and/or neurological—organ systems that was not the primary site of infection. Septic shock was defined as children with sepsis who had cardiovascular dysfunction, indicated by at least 1 cardiovascular point in the Phoenix Sepsis Score, which included severe hypotension for age, blood lactate exceeding 5 mmol/L, or need for vasoactive medication. Children with septic shock had an in-hospital mortality rate of 10.8% and 33.5% in higher- and lower-resource settings, respectively.

Conclusions and Relevance  The Phoenix sepsis criteria for sepsis and septic shock in children were derived and validated by the international SCCM Pediatric Sepsis Definition Task Force using a large international database and survey, systematic review and meta-analysis, and modified Delphi consensus approach. A Phoenix Sepsis Score of at least 2 identified potentially life-threatening organ dysfunction in children younger than 18 years with infection, and its use has the potential to improve clinical care, epidemiological assessment, and research in pediatric sepsis and septic shock around the world.

DOI: 10.1001/jama.2024.0179

Source: https://jamanetwork.com/journals/jama/fullarticle/2814297