Abstract
Objective: To study warning signs of serious infections in febrile children presenting to PED, ascertain their risk of having sepsis, and evaluate their management.Design: Prospective observational study.Setting: A single pediatric emergency department (PED).Participants: Febrile children, aged 1 month−16 years, with >= 1 warning signs of sepsis.Interventions and Main outcome measures: Clinical characteristics, including different thresholds for tachycardia and tachypnoea, and their association with (1) delivery of pediatric sepsis 6 (PS6) interventions, (2) final diagnosis of invasive bacterial infection (IBI), (3) the risk for pediatric intensive care unit (PICU) admission, and (4) death.Results: Forty-one percent of 5,156 febrile children had warning signs of sepsis. 1,606 (34%) children had tachypnoea and 1,907 (39%) children had tachycardia when using APLS threshold values. Using the NICE sepsis guidelines thresholds resulted in 1,512 (32%) children having tachypnoea (kappa 0.56) and 2,769 (57%) children having tachycardia (kappa 0.66). Of 1,628 PED visits spanning 1,551 disease episodes, six children (0.4%) had IBI, with one death (0.06%), corresponding with 256 children requiring escalation of care according to sepsis guideline recommendations for each child with IBI. There were five additional PICU admissions (0.4%). 121 (7%) had intravenous antibiotics in PED; 39 children (2%) had an intravenous fluid bolus, inotrope drugs were started in one child. 440 children (27%) were reviewed by a senior clinician. In 4/11 children with IBI or PICU admission or death, PS6 interventions were delivered within 60 min after arriving. 1,062 (65%) visits had no PS6 interventions. Diagnostic performance of vital signs or sepsis criteria for predicting serious illness yielded a large proportion of false positives. Lactataemia was not associated with giving iv fluid boluses (p = 0.19) or presence of serious bacterial infections (p = 0.128).Conclusion: Many febrile children (41%) present with warning signs for sepsis, with only few of them undergoing investigations or treatment for true sepsis. Children with positive isolates in blood or CSF culture presented in a heterogeneous manner, with varying levels of urgency and severity of illness. Delivery of sepsis care can be improved in only a minority of children with IBI or admitted to PICU.
Highlights
A majority of children with an acute infectious illness presenting to emergency care facilities will have a self-limiting illness [1]
We evaluated the clinical management of children with warning signs of sepsis, with a specific focus on those children admitted to pediatric intensive care unit (PICU) and a confirmed invasive bacterial infection
Pediatric Sepsis Criteria and Different Thresholds of Vital Signs We looked at the number of children having tachycardia or tachypnoea by using different thresholds as defined by [1] Advanced Pediatric Life Support (APLS) thresholds and [2] thresholds used in the National Institute of Health Care Excellence (NICE) guidelines on the early detection and management of sepsis [13], which correspond with the 99th centiles for respiratory rate and heart rate described in the meta-analysis by Fleming et al [20]
Summary
A majority of children with an acute infectious illness presenting to emergency care facilities will have a self-limiting illness [1]. Worse outcomes in children with sepsis presenting to emergency departments are associated with the failure to recognize children with sepsis early, the absence of specialist supervision, and subsequent failure of escalating care to a more senior clinician [4], as well as delayed administration of parenteral antibiotics [5]. Most clinical algorithms are based on abnormal vital parameters, such as heart rate, respiratory rate, temperature, capillary refill time, and decreased level of consciousness. These abnormal vital parameters are seen in a large proportion of children whose fever is due to self-limiting infectious disease [12]. Children are often able to maintain normal haemodynamic parameters in the early stages of sepsis, complicating the use of vital sign-based tools for the detection of sepsis
Sign-in/Register to view highlights & summary Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
