Sepsis is an important cause of mortality and morbidity in the pediatric intensive care unit, early identification and therapeutic interventions is the cornerstone in the outcome of sepsis, early recognition of sepsis is not always straightforward and clinical signs at presentation can be misleading due to frequent comorbidities or variable demographic characteristics. (27)
Cardiac dysfunction is one of the main causes of clinical deterioration in pediatric patients (16), the echocardiogram is already used in the management of patients with septic shock during volumetric resuscitation and to choose the best vasoactive drug (18), evaluations obtained by echocardiographic assessment can be used as markers of sepsis, few studies have associated these measures with unfavorable outcomes in pediatric sepsis (20).
Our study aimed to verify the association between serum ferritin levels and cardiac dysfunction with unfavorable outcomes in pediatric sepsis.
This present study was conducted on 40 infants and children suffering from sepsis of different causes admitted in the pediatric intensive care unit at Minia University Children and Maternal hospital, department of pediatrics. 85% of cases were between 1 month and 2 years, they were 24 females (60%) and 16 males (40%).
Ferritin was the most prominent inflammatory marker in our study. It is an iron-storing protein, responsible for releasing it in a controlled way. In inflammatory processes, a great production of ferritin occurs, inducing a decrease in serum iron, believed to decrease the availability of iron to microorganisms. For this reason, ferritin in critically ill pediatric patients may be increased, and it is associated with severity in some illnesses (7).
C-reactive protein is an acute-phase reactant; it rises within six hours of the onset of inflammation and may raise to 10,000 folds with a peak at 48 hours, and disappears equally rapidly after the destructive process has stopped. CRP is not only useful in detecting the presence of an inflammatory disease but is also useful in following its progress and effectiveness of treatment. In particular serial measurements of CRP are very useful, for instance when one has to decide about the duration of antibiotic therapy in infection (28).
The diagnoses of the studied cases were three main categories: pneumonia (50%), central nervous system (CNS) infection (30%), and gastroenteritis (20%). The etiology of increase the risk of pneumonia may include environmental factors, genetic susceptibility, and ethnic causes (29). In this respect (Weiss et al., 2014) carried a study on the global epidemiology of pediatric sepsis and found that the most frequent site of infection was the respiratory system with pneumonia (40%). (30)
This present study showed that there was a highly statistically significant difference between a day of admission D1 and third day as regard to C-reactive protein with median value of CRP was higher on the day of admission 48 mg/L (24–104) compared to third day that was 24 mg/L (12–48) with P-value < 0.001.
Our study showed that there was a highly statistically significant difference between a day of admission D1 and third day as regard to serum ferritin level with median value of Ferritin level was higher on the day of admission 522 ng/ml (395–652) compared to third day that was 400 ng/ml (335.5–562) with P-value < 0.001.
In the current study, we found that the median value of Ferritin level was significantly higher among nonsurvivors septic cases 565 ng/ml (453.5-769.5) than survivors septic cases 456.5 ng/ml (347.5–539) with p-value = 0.021. This result agrees with (Bennett et al., 2011) (35) who found that very high serum ferritin levels are associated with high mortality in pediatric intensive care patients.
Our current study showed that cardiac dysfunction (EF < 55%) was present among 47.5% of the studied cases. This finding of cardiac dysfunction in sepsis (low Ejection fraction) of 47.5% of cases is higher than studies published by (Raj et al., 2014) (16) 37% of cases ;( Pulido et al., 2012) (33) 27% of cases; and (Furian et al., 2012) (34) 33% of cases.
The current study showed that the median value of Ejection fraction% was significantly lower among non-survivors 44% (36.5–55.5) than survivors with sepsis 60% (58.5–65.5) with P-value < 0.001.
This comes in agreement with (Elgazzar et al., 2018) (32) whose study carried out on 50 pediatric patients admitted to the pediatric intensive care unit (PICU) of Menoufia University Hospital with septic shock and found decreased EF% was higher among died than improved septic cases.
The present study showed that the number of cases died with cardiac dysfunction (18 patients 94.7%) was higher than that with no cardiac dysfunction (6 patients 28.6%) with p-value < 0.001.
In our study, we found that the median value of serum Ferritin level was significantly higher among cases with cardiac dysfunction than cases without cardiac dysfunction. In this respect (Tonial et al., 2017) (31) found that the mean value of serum Ferritin level was significantly higher among cases with cardiac dysfunction than those without cardiac dysfunction.
In our study, we found a statistically significant difference between cases with cardiac dysfunction and those without cardiac dysfunction as regard to duration of mechanical ventilation (hr) with p-value < 0.001, duration of inotropes (hr) with p-value 0.002, and maximum inotropic score with P-value < 0.001 while there was no statistically significant difference between cases with cardiac dysfunction and those without cardiac dysfunction as regard to duration of PICU admission (days) with P-value 0.713.
(Garcia et al., 2007) (6) found a statistically significant difference between cases with cardiac dysfunction and those without cardiac dysfunction as regards to duration of mechanical ventilation (hr) with P-value = 0.011, duration of PICU admission (days) with P-value = 0.02, and maximum inotropic score with P-value = 0.001. while there was no statistically significant difference between cases with cardiac dysfunction and those without cardiac dysfunction as regards to duration of inotropes (hr) with P-value = 0.231.
The receiver operating characteristics area under the curve (ROC-AUC) value of ferritin level > 550 ng/ml as cut point was 0.741 has a sensitivity of 62.5% and specificity of 81.2%. in prediction of mortality among studied patients.
Factors found to be significantly associated with mortality by univariable analysis were entered the multivariable model to detect the significant predictors of mortality, cardiac dysfunction, and serum ferritin were found to be predictors of mortality. Patients with cardiac dysfunction were more likely to die than patients without cardiac dysfunction (p = 0.035), the increase in serum ferritin by 10 units was associated with a 10% increase in the odds of child to die (AOR = 1.01, 95% CI = 1.0–1.02).
(Garica et al., 2007) (6) found ferritin level > 500 ng/ml is associated with a higher mortality rate with P-value 0.02.