Inotropes, Absolute Monocyte Counts and Survival of Children with Septic Shock

Background: Monocytes play important role in immune modulation during sepsis. Monocyte dysfunction is known to affect the outcomes in septic patients. The current study evaluates the association between inotrope usage, absolute monocyte count and survival of critically ill children with septic shock. Methods: Charts of all children who received vasoactive medications during one calendar year and admitted to a paediatric intensive care unit (PICU) were reviewed. Children with immunodeficiency, cardiogenic shock, and post-operative conditions were excluded. Data collected included total and absolute blood cell counts, serum electrolytes, dosages of inotropes, use of supportive measures, outcomes, paediatric index of mortality (PIM-2) scores, and PICU length of stay. Daily laboratory values were collected for 5 days from the start of vasoactive support. Data from children who survived were compared with those expired. Main Results: Records of 26 children who were admitted to PICU with septic shock were analysed. The mortality rate was 15.4%. These children received multiple supportive therapies including insulin (23%), hydrocortisone (42%), nitric oxide (15%), diuretics (61.5%), blood products (77%), ventilator support (85%), sedatives and analgesics (89%), and paralytics (61.5%). There were no significant differences in their use, minimum and maximum absolute monocytes counts, length of stay, PIM-2 score, and cumulative inotropic score between those who survived versus those who expired. All 4 patients who died received more than one vasoactive medication on day 1 of septic shock compared to only 10 (45%) among those who survived (p<0.05). Lower proportion of survivors received inotropic support for >= 5 days (27% vs 75%; p=0.03). The relative risk of death if epinephrine was used on first day is 7.7 [95% CI (1.6-36.0), p=0.0099]. The change in absolute monocyte count (max-min count) was lower in those who survived (733 vs 1293x10(9)/dL; p<0.05). Conclusion: Epinephrine and the number of inotrope use on first day are associated with non-survival. Absolute monocyte count fluctuation is less among children who survived septic shock compared to those who die with septic shock.