The diagnosis of sepsis is based upon the clinical recognition of a constellation of several, fairly consistent clinical signs and symptoms that occur in association with an infection or other inciting event, e.g. trauma, pancreatitis, cardiopulmonary bypass, or burns. Roger Bone first coined the term sepsis syndrome
in 1989 (11
), and shortly thereafter, an international panel of experts from the Society of Critical Care Medicine (SCCM) and the American College of Chest Physicians (ACCP) proposed the now familiar consensus definitions for the systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock () (12
). These definitions have been subsequently modified for use in critically ill children () (13
) and are certainly applicable to children with CHD.
American College of Physicians (ACCP)/Society of Critical Care Medicine (SCCM) Consensus Definitions for SIRS, Infection, Sepsis, Severe Sepsis, and Septic Shock
Consensus Definitions for Pediatric SIRS, Infection, Sepsis, Severe Sepsis, and Septic Shock
According to the National Center for Health Statistics and the Centers for Disease Control and Prevention, sepsis was the 10th
leading cause of death overall in 2007 (14
). Recent estimates suggest that there are between 77 to 240 new cases of sepsis per 100,000 population each year (15
). The population is growing older, and patients are living longer, even in the face of diseases that were previously considered universally fatal. Hospitalized patients are becoming more dependent upon the use of invasive devices and technology, all of which are associated with increased risk of infection. As such, the incidence of sepsis is expected to increase by 1.5% every year, resulting in an additional 1 million cases per year by 2020 (15
). The story in children is fairly similar. There are between 20,000 – 42,000 cases of severe sepsis every year in the United States alone, half of which occur in children with underlying diseases like cancer and congenital heart disease (19
). Again, as more children survive diseases that were previously fatal (21
), the incidence of sepsis will likely increase further.
While the management of critically ill patients with sepsis is certainly better now compared to 20 years ago (22
), sepsis-associated mortality remains unacceptably high. Recent estimates suggest that there are approximately 4,500 children who die every year from sepsis in the United States alone (19
). The actual number of deaths associated with sepsis is likely to be much higher, as many patients usually die from sepsis during the course of an underlying disease, such as prematurity, congenital heart disease, or cancer. In many of these cases, deaths are frequently attributed to the underlying disease process, rather than to sepsis (17
). According to data from the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), and the Bill and Melinda Gates Foundation, nearly 70% of the 8 million deaths in children < 5 years of age were due to infectious disease (28
). As sepsis is the final common pathway in many infectious diseases, such as malaria, dengue fever, pneumonia, influenza, and HIV, sepsis can and should be considered the #1 killer of children worldwide.
Unfortunately, there are relatively few studies that have determined the impact of sepsis on critically ill children with CHD (29
). Most of these studies are limited to critically ill children who develop sepsis secondary to hospital-acquired infections (HAIs), including (in decreasing order of frequency and importance in the CICU) catheter-associated bloodstream infections (CA-BSIs), ventilator-associated respiratory infections (VARIs), surgical site infections (SSIs), and catheter-associated urinary tract infections (CA-UTIs) (5
). Barker and colleagues (31
) reviewed 30,078 cases from 48 centers in the Society of Thoracic Surgeons Congenital Heart Surgery Database from 2002–2006 and found that 2.8% of these cases had a major infectious complication, of which 2.6% were sepsis. Mortality and postoperative length of stay were significantly greater in these patients. More studies on the epidemiology of sepsis in children with CHD are therefore necessary and warranted.