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Soulages Arrese N, Green ML. Fluid management of the critically Ill child. Curr Opin Pediatr 2023; 35:239-244. [PMID: 36472133 DOI: 10.1097/mop.0000000000001210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW This review summarizes current literature pertaining to fluid management for critically ill children. It includes an overview on crystalloid fluid used throughout the critical illness course, management of fluid output and complications with fluid overload. RECENT FINDINGS Observational paediatric studies and adult randomized trials show mixed results regarding risk of mortality and kidney injury with 0.9% saline and crystalloid fluid. A recent adult randomized trial suggests that a fluid restrictive strategy may be well tolerated in critically ill adults with septic shock, but further randomized trials are needed in paediatrics. Fluid overload has been associated with increased morbidity and mortality. Trials exploring ways to decrease fluid accumulation must be done in paediatrics. SUMMARY Additional high-quality studies are needed to precisely define the type, timing and rate of intravenous fluid critically ill children should receive throughout their clinical illness course.
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Affiliation(s)
- Natalia Soulages Arrese
- University of Texas Southwestern Medical Center, Department of Pediatrics, Division of Critical Care Medicine, Dallas, Texas, USA
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Mercurio L, Pou S, Duffy S, Eickhoff C. Risk Factors for Pediatric Sepsis in the Emergency Department: A Machine Learning Pilot Study. Pediatr Emerg Care 2023; 39:e48-e56. [PMID: 36648121 DOI: 10.1097/pec.0000000000002893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To identify underappreciated sepsis risk factors among children presenting to a pediatric emergency department (ED). METHODS A retrospective observational study (2017-2019) of children aged 18 years and younger presenting to a pediatric ED at a tertiary care children's hospital with fever, hypotension, or an infectious disease International Classification of Diseases (ICD)-10 diagnosis. Structured patient data including demographics, problem list, and vital signs were extracted for 35,074 qualifying ED encounters. According to the Improving Pediatric Sepsis Outcomes Classification, confirmed by expert review, 191 patients met clinical sepsis criteria. Five machine learning models were trained to predict sepsis/nonsepsis outcomes. Top features enabling model performance (N = 20) were then extracted to identify patient risk factors. RESULTS Machine learning methods reached a performance of up to 93% sensitivity and 84% specificity in identifying patients who received a hospital diagnosis of sepsis. A random forest classifier performed the best, followed by a classification and regression tree. Maximum documented heart rate was the top feature in these models, with importance coefficients (ICs) of 0.09 and 0.21, which represent how much an individual feature contributes to the model. Maximum mean arterial pressure was the second most important feature (IC 0.05, 0.13). Immunization status (IC 0.02), age (IC 0.03), and patient zip code (IC 0.02) were also among the top features enabling models to predict sepsis from ED visit data. Stratified analysis revealed changes in the predictive importance of risk factors by race, ethnicity, oncologic history, and insurance status. CONCLUSIONS Machine learning models trained to identify pediatric sepsis using ED clinical and sociodemographic variables confirmed well-established predictors, including heart rate and mean arterial pressure, and identified underappreciated relationships between sepsis and patient age, immunization status, and demographics.
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Affiliation(s)
- Laura Mercurio
- From the Section of Pediatric Emergency Medicine, Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI
| | - Sovijja Pou
- Alpert Medical School of Brown University, Providence, RI
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Crilly J, Huang Y, Krahe M, Wilhelms D, Ekelund U, Hörlin E, Hayes J, Keijzers G. Research priority setting in emergency care: A scoping review. J Am Coll Emerg Physicians Open 2022; 3:e12852. [PMID: 36518881 PMCID: PMC9742830 DOI: 10.1002/emp2.12852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 09/13/2022] [Accepted: 10/26/2022] [Indexed: 12/14/2022] Open
Abstract
Objective Priority areas for emergency care research are emerging and becoming ever more important. The objectives of this scoping review were to (1) provide a comprehensive overview of published emergency care priority-setting studies by collating and comparing priority-setting methodology and (2) describe the resulting research priorities identified. Methods The Joanna Briggs Institute methodological framework was used. Inclusion criteria were peer-review articles available in English, published between January 1, 2008 and March 31, 2019 and used 2 or more search terms. Five databases (Scopus, AustHealth, EMBASE, CINAHL, and Ovid MEDLINE) were searched. REporting guideline for PRIority SEtting of health research (REPRISE) criteria were used to assess the quality of evidence of included articles. Results Forty-five studies were included. Fourteen themes for emergency care research were considered within 3 overarching research domains: emergency populations (pediatrics, geriatrics), emergency care workforce and processes (nursing, shared decision making, general workforce, and process), and emergency care clinical areas (imaging, falls, pain management, trauma care, substance misuse, infectious diseases, mental health, cardiology, general clinical care). Variation in the reporting of research priority areas was evident. Priority areas to drive the global agenda for emergency care research are limited given the country and professional group-specific context of existing studies. Conclusion This comprehensive summary of generated research priorities across emergency care provides insight into current and future research agendas. With the nature of emergency care being inherently broad, future priorities may warrant population (eg, children, geriatrics) or subspecialty (eg, trauma, toxicology, mental health) focus and be derived using a rigorous framework and patient engagement.
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Affiliation(s)
- Julia Crilly
- Department of Emergency MedicineGold Coast Hospital and Health ServiceQueenslandGold CoastAustralia
- School of Nursing and MidwiferyGriffith UniversityGold CoastQueenslandAustralia
- Menzies Health Institute QueenslandGriffith UniversityGold CoastQueenslandAustralia
| | - Ya‐Ling Huang
- Department of Emergency MedicineGold Coast Hospital and Health ServiceQueenslandGold CoastAustralia
- School of Nursing and MidwiferyGriffith UniversityGold CoastQueenslandAustralia
- Faculty of Health (Nursing)Southern Cross UniversityQueenslandGold CoastAustralia
| | - Michelle Krahe
- Office of the Pro Vice Chancellor (Indigenous)Griffith UniversityMeadowbrookQueenslandAustralia
| | - Daniel Wilhelms
- Department of Emergency MedicineLocal Health Care ServicesCentral ÖstergötlandLinköpingSweden
- Department of Biomedical and Clinical SciencesLinköping UniversitySweden
| | - Ulf Ekelund
- Department of Clinical SciencesFaculty of MedicineLund UniversityLundSweden
| | - Erika Hörlin
- Department of Emergency MedicineLocal Health Care ServicesCentral ÖstergötlandLinköpingSweden
- Department of Biomedical and Clinical SciencesLinköping UniversitySweden
| | - Jessica Hayes
- Department of Emergency MedicineGold Coast Hospital and Health ServiceQueenslandGold CoastAustralia
- School of Nursing and MidwiferyGriffith UniversityGold CoastQueenslandAustralia
| | - Gerben Keijzers
- Department of Emergency MedicineGold Coast Hospital and Health ServiceQueenslandGold CoastAustralia
- Faculty of Health Sciences and MedicineBond UniversityGold CoastQueenslandAustralia
- School of MedicineGriffith UniversityGold CoastQueenslandAustralia
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Hou SK, Lin HA, Tsai HW, Lin CF, Lin SF. Monocyte Distribution Width in Children With Systemic Inflammatory Response: Retrospective Cohort Examining Association With Early Sepsis. Pediatr Crit Care Med 2022; 23:698-707. [PMID: 35704311 DOI: 10.1097/pcc.0000000000003019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To investigate the association between increased monocyte distribution width (MDW) and pediatric sepsis in the emergency department (ED). DESIGN Retrospective cohort study. SETTING A single academic hospital study. PATIENTS Patients from birth to the age of 18 years who presented at the ED of an academic hospital with systemic inflammatory response syndrome (SIRS) were consecutively enrolled. Sepsis was diagnosed using the International Pediatric Surviving Sepsis Campaign criteria. INTERVENTIONS Antibiotic treatment was administrated once infection was suspected. MEASUREMENTS AND MAIN RESULTS Routine complete blood cell count, neutrophil-to-lymphocyte ratio (NLR), and MDW, a new inflammatory biomarker, were evaluated in the ED. Logistic regression models were used to explore associations with early pediatric sepsis. We included 201 patients with sepsis and 1,050 without sepsis. In the multivariable model, MDW greater than 23 U (odds ratio [OR], 4.97; 95% CI, 3.42-7.22; p < 0.0001), NLR greater than 6 (OR, 2.06; 95% CI, 1.43-2.94; p = 0.0001), WBC greater than 11,000 cells/µL (OR, 6.52; 95% CI, 4.45-9.53; p < 0.0001), and the SIRS score (OR, 3.42; 95% CI, 2.57-4.55; p < 0.0001) were associated with pediatric sepsis. In subgroup analysis, MDW greater than 23 U remained significantly associated with sepsis for children 6-12 years old (OR, 6.76; 95% CI, 2.60-17.57; p = 0.0001) and 13-18 years (OR, 17.49; 95% CI, 7.69-39.76; p = 0.0001) with an area under the receiver operating curve of 0.8-0.9. CONCLUSIONS MDW greater than 23 U at presentation is associated with the early diagnosis of sepsis in children greater than or equal to 6 years old. This parameter should be considered as a stratification variable in studies of pediatric sepsis.
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Affiliation(s)
- Sen-Kuang Hou
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hui-An Lin
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Hung-Wei Tsai
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chiou-Feng Lin
- Department of Microbiology and Immunology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Sheng-Feng Lin
- Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Affiliation(s)
- Scott L. Weiss
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Pediatric Sepsis Program at the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Fran Balamuth
- Pediatric Sepsis Program at the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Weiss SL, Balamuth F, Long E, Thompson GC, Hayes KL, Katcoff H, Cook M, Tsemberis E, Hickey CP, Williams A, Williamson-Urquhart S, Borland ML, Dalziel SR, Gelbart B, Freedman SB, Babl FE, Huang J, Kuppermann N. PRagMatic Pediatric Trial of Balanced vs nOrmaL Saline FlUid in Sepsis: study protocol for the PRoMPT BOLUS randomized interventional trial. Trials 2021; 22:776. [PMID: 34742327 PMCID: PMC8572061 DOI: 10.1186/s13063-021-05717-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 10/11/2021] [Indexed: 12/24/2022] Open
Abstract
Background/aims Despite evidence that preferential use of balanced/buffered fluids may improve outcomes compared with chloride-rich 0.9% saline, saline remains the most commonly used fluid for children with septic shock. We aim to determine if resuscitation with balanced/buffered fluids as part of usual care will improve outcomes, in part through reduced kidney injury and without an increase in adverse effects, compared to 0.9% saline for children with septic shock. Methods The Pragmatic Pediatric Trial of Balanced versus Normal Saline Fluid in Sepsis (PRoMPT BOLUS) study is an international, open-label pragmatic interventional trial being conducted at > 40 sites in the USA, Canada, and Australia/New Zealand starting on August 25, 2020, and continuing for 5 years. Children > 6 months to < 18 years treated for suspected septic shock with abnormal perfusion in an emergency department will be randomized to receive either balanced/buffered crystalloids (intervention) or 0.9% saline (control) for initial resuscitation and maintenance fluids for up to 48 h. Eligible patients are enrolled and randomized using serially numbered, opaque envelopes concurrent with clinical care. Given the life-threatening nature of septic shock and narrow therapeutic window to start fluid resuscitation, patients may be enrolled under “exception from informed consent” in the USA or “deferred consent” in Canada and Australia/New Zealand. Other than fluid type, all decisions about timing, volume, and rate of fluid administration remain at the discretion of the treating clinicians. For pragmatic reasons, clinicians will not be blinded to study fluid type. Anticipated enrollment is 8800 patients. The primary outcome will be major adverse kidney events within 30 days (MAKE30), a composite of death, renal replacement therapy, and persistent kidney dysfunction. Additional effectiveness, safety, and biologic outcomes will also be analyzed. Discussion PRoMPT BOLUS will provide high-quality evidence for the comparative effectiveness of buffered/balanced crystalloids versus 0.9% saline for the initial fluid management of children with suspected septic shock in emergency settings. Trial registration PRoMPT BOLUS was first registered at ClinicalTrials.gov (NCT04102371) on September 25, 2019. Enrollment started on August 25, 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05717-4.
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Affiliation(s)
- Scott L Weiss
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. .,The Children's Hospital of Philadelphia Pediatric Sepsis Program, Philadelphia, PA, USA.
| | - Fran Balamuth
- The Children's Hospital of Philadelphia Pediatric Sepsis Program, Philadelphia, PA, USA.,Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Elliot Long
- Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Victoria, Australia.,Departments of Pediatrics and Critical Care, The University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Graham C Thompson
- Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Katie L Hayes
- The Children's Hospital of Philadelphia Pediatric Sepsis Program, Philadelphia, PA, USA
| | - Hannah Katcoff
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marlena Cook
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Elena Tsemberis
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher P Hickey
- The Children's Hospital of Philadelphia Pediatric Sepsis Program, Philadelphia, PA, USA
| | - Amanda Williams
- Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Sarah Williamson-Urquhart
- Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Meredith L Borland
- Divisions of Emergency Medicine and Pediatrics, Perth Children's Hospital, School of Medicine at the University of Western Australia, Crawley, Australia
| | - Stuart R Dalziel
- Departments of Surgery and Pediatrics: Child and Youth Health, Starship Children's Hospital, University of Auckland, Auckland, New Zealand
| | - Ben Gelbart
- Departments of Pediatrics and Critical Care, The University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Society Paediatric Study Group, Camberwell, Australia.,Paediatric Intensive Care Unit, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Franz E Babl
- Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Victoria, Australia.,Departments of Pediatrics and Critical Care, The University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Jing Huang
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Nathan Kuppermann
- Department of Emergency Medicine and Pediatrics, UC Davis School of medicine and UC Davis Health, Sacramento, CA, USA
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Multidisciplinary Kaizen Event to Improve Adherence to a Sepsis Clinical Care Guideline. Pediatr Qual Saf 2021; 6:e435. [PMID: 34235357 PMCID: PMC8225368 DOI: 10.1097/pq9.0000000000000435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 01/21/2021] [Indexed: 12/29/2022] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: Since 2015, the Ann and Robert H. Lurie Children’s Hospital Emergency Department (ED) has improved the recognition and treatment of pediatric sepsis and septic shock. Despite existing clinical care guidelines, the ED had not yet achieved the Surviving Sepsis Campaign timeliness goals for fluid and antibiotic administration. Methods: The team conducted a multidisciplinary Kaizen event to evaluate clinical workflows and identify opportunities to improve sepsis care adherence. Using rigorous quality improvement methodology, frontline providers mapped workflows to identify barriers and prioritize emerging solutions. Results: Thirty-seven staff members across 17 disciplines participated. Nurses and physicians identified communication gaps at pathway initiation. Access to supplies, inadequate task delegation, and a lack of urgency for a subset of pathway patients delayed treatment. Prioritized interventions included scripted communication tools, a delineated response plan, and standardized reassessment processes. Revisions to the key driver diagram were made after the improvement event, guiding future plan-do-study-act cycles. Conclusions: Frontline provider participation in the Kaizen event uncovered barriers to care and identified the root causes of ineffective communication and system process inefficiencies. Engaging key stakeholders from multiple care areas in a candid context was a novel approach to process improvement within our department. The Kaizen methodology is fundamental to developing sustainable quality improvement practices, creating momentum for a continuous improvement culture to engrain quality improvement in practice. The success of Kaizen will shape the format of future ED improvement projects.
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8
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Valentino K, Campos GJ, Acker KA, Dolan P. Abnormal Vital Sign Recognition and Provider Notification in the Pediatric Emergency Department. J Pediatr Health Care 2020; 34:522-534. [PMID: 32709522 DOI: 10.1016/j.pedhc.2020.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 05/08/2020] [Accepted: 05/14/2020] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Vital signs measurements aid in the early identification of patients at risk of clinical deterioration and determining the severity of illness. Health care providers rely on registered nurses to document vital signs and communicate abnormalities. The purpose of this project was to improve the provider notification process regarding abnormal vital signs in a pediatric emergency department. METHOD A best practice advisory (BPA) was piloted by the advanced practice providers in the pediatric emergency department. To evaluate the effects of the BPA, a mixed-methods study was employed. RESULTS Implementation of the BPA improved the provider notification process and enhanced clinical decision making. The percentage of patients discharged home with abnormal respiratory rates (10.9% vs. 5.9%, p = .31), abnormal temperatures (15.6% vs. 7.5%, p = .14), and abnormal heart rates (25% vs. 11.9%, p = .11) improved. DISCUSSION Creation and implementation of the BPA improved the abnormal vital sign communication process to providers at this single institution.
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Abstract
Early diagnosis and treatment of sepsis and septic shock in children results in improved outcomes. However, diagnosis is hampered by lack of specific diagnostic tests and relies on the recognition of the alterations of vital signs and protean systemic manifestations associated with infections, signs that mimic many critical illnesses. As a result, the early diagnosis of sepsis is usually presumptive and is based on the suspicion or presence of an infection in combination with the systemic changes. Suspicion should be heightened in vulnerable risk groups such as those with immune compromise due to underlying disease or medication use. Thus, on many occasions, treatment of sepsis is initiated on clinical suspicion pending the outcomes of ongoing evaluations and laboratory findings.What is of relevance to the emergency clinicians is the initial recognition, resuscitation, and treatment in the first few hours of presentation. To best accomplish these tasks, contemporary guidelines suggest that the use of a "recognition bundle" containing a trigger tool for rapid identification, a "resuscitation and stabilization bundle" to enable adherence to best practice, and a "performance bundle" to identify and overcome barriers to best practice be used.Although there are no universally acceptable tools to accomplish these tasks, the various iterations used in quality improvement initiatives have consistently demonstrated better care processes and outcomes. In this article, we outline the contemporary approach to sepsis in the first hours after presentation.
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10
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Balamuth F, Alpern ER, Kan M, Shumyatcher M, Hayes K, Lautenbach E, Himes BE. Gene Expression Profiles in Children With Suspected Sepsis. Ann Emerg Med 2020; 75:744-754. [PMID: 31983492 DOI: 10.1016/j.annemergmed.2019.09.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 09/09/2019] [Accepted: 09/24/2019] [Indexed: 11/27/2022]
Abstract
STUDY OBJECTIVE Sepsis recognition is a clinical challenge in children. We aim to determine whether peripheral blood gene expression profiles are associated with pathogen type and sepsis severity in children with suspected sepsis. METHODS This was a prospective pilot observational study in a tertiary pediatric emergency department with a convenience sample of children enrolled. Participants were older than 56 days and younger than 18 years, had suspected sepsis, and had not received broad-spectrum antibiotics in the previous 4 hours. Primary outcome was source pathogen, defined as confirmed bacterial source from sterile body fluid or confirmed viral source. Secondary outcome was sepsis severity, defined as maximum therapy required for shock reversal in the first 3 hospital days. We drew peripheral blood for ribonucleic acid isolation at the sepsis protocol activation, obtained gene expression measures with the GeneChip Human Gene 2.0 ST Array, and conducted differential expression analysis. RESULTS We collected ribonucleic acid samples from a convenience sample of 122 children with suspected sepsis and 12 healthy controls. We compared the 66 children (54%) with confirmed bacterial or viral infection and found 558 differentially expressed genes, many related to interferon signaling or viral immunity. We did not find statistically significant gene expression differences in patients according to sepsis severity. CONCLUSION The study demonstrates feasibility of evaluating gene expression profiling data in children evaluated for sepsis in the pediatric emergency department setting. Our results suggest that gene expression profiling may facilitate identification of source pathogen in children with suspected sepsis, which could ultimately lead to improved tailoring of sepsis treatment and antimicrobial stewardship.
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Affiliation(s)
- Fran Balamuth
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Elizabeth R Alpern
- Department of Pediatrics, Northwestern School of Medicine, Division of Emergency Medicine, and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Mengyuan Kan
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Maya Shumyatcher
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Katie Hayes
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ebbing Lautenbach
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Blanca E Himes
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
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Piehl M, Smith-Ramsey C, Teeter WA. Improving fluid resuscitation in pediatric shock with LifeFlow ®: a retrospective case series and review of the literature. Open Access Emerg Med 2019; 11:87-93. [PMID: 31118839 PMCID: PMC6503651 DOI: 10.2147/oaem.s188110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 02/28/2019] [Indexed: 11/23/2022] Open
Abstract
Rapid delivery of an intravenous fluid bolus is commonly used in pediatric emergency care for the treatment of shock and hypotension. Early fluid delivery targeted at shock reversal results in improved patient outcomes, yet current methods of fluid resuscitation often limit the ability of providers to achieve fluid delivery goals. We report on the early clinical experience of a new technique for rapid fluid resuscitation. The LifeFlow® infuser is a manually operated device that combines a syringe, automatic check valve, and high-flow tubing set with an ergonomic handle to enable faster and more efficient delivery of fluid by a single health care provider. LifeFlow is currently FDA-cleared for the delivery of crystalloid and colloids. Four cases are presented in which the LifeFlow device was used for emergent fluid resuscitation: a 6-month-old with septic shock, a 2-year-old with intussusception and shock, an 11-year-old with pneumonia and septic shock, and a 15-year-old with trauma and hemorrhagic shock.
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Affiliation(s)
- Mark Piehl
- Department of Pediatrics, Division of Pediatric Critical Care, WakeMed Health and Hospitals, Raleigh, NC, USA.,410 Medical, Inc, Durham, NC, USA.,Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA.,Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Cherrelle Smith-Ramsey
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - William A Teeter
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Abstract
Sepsis is a life-threatening condition that requires aggressive, timely, and multi-disciplinary care. Understanding the changes in national guidelines regarding definitions, diagnosis and the management of pediatric sepsis is critical for the pediatric surgeon participating in the care of these patients. The purpose of this article is to review the essential steps for the timely management of pediatric sepsis, including fluid resuscitation, antibiotics, vasopressors, and steroids. This includes a description of the key adjunct modalities of treatment, including renal replacement therapy and extracorporeal life support (ECLS).
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Affiliation(s)
- Laura A Boomer
- Children's Hospital of Richmond, Virginia Commonwealth University, 1000 East Broad St. Richmond, Richmond, VA 23219, USA.
| | - Alexander Feliz
- Lebonheur Children's Hospital and The University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
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13
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Depinet HE, Eckerle M, Semenova O, Meinzen-Derr J, Babcock L. Characterization of Children with Septic Shock Cared for by Emergency Medical Services. PREHOSP EMERG CARE 2019; 23:491-500. [DOI: 10.1080/10903127.2018.1539147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Mojtahedi SY, Rahbarimanesh A, Khedmat L, Izadi A. The Prevalence of Risk Factors for the Development of Bacteraemia in Children. Open Access Maced J Med Sci 2018; 6:2023-2029. [PMID: 30559854 PMCID: PMC6290420 DOI: 10.3889/oamjms.2018.418] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 10/12/2018] [Accepted: 10/14/2018] [Indexed: 11/13/2022] Open
Abstract
AIM: The objective of this study was to evaluate the frequency of risk factors for bacteremia in children less than 15 years of age was determined in Bahrami Hospital during 2013-2016. METHODS: This study conducted on 84 children aged 3 months’ to15 years old, who hospitalised in the pediatrics ward and the PICU in Bahrami Hospital from 2012 to 2016. Our study consisted of 46 boys (54.2%) and 38 girls. Moreover, 24.1% of subjects (20 patients) were entered in the study as young as three months old, followed by three months to three years (49.4 %; 41 subjects), and 3 to 15 years of age (26.5%; 22 individuals). RESULTS: The average hospitalization duration was determined to be 15.30 ± 8.75 days. Moreover, our results revealed that a history of blood transfusion in 11.2% of patients. On the other hand, 35.7% of cases were determined to be positive for blood cultures. The microorganisms reported from positive blood cultures include Enterobacter (81.48%), Escherichia coli (11.11%) and Klebsiella (3.70%). Also, 50% of patients were hospitalised in the internal ward, 12% received immunosuppressive drugs, and 96.4% of the patients had a history of vaccination. CONCLUSION: Pediatric severe sepsis remains a burdensome public health problem, with prevalence, morbidity, and mortality rates similar to those reported in critically ill adult populations. International clinical trials targeting children with severe sepsis are warranted.
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Affiliation(s)
- Sayed Yousef Mojtahedi
- Department of Pediatric Nephrology, Bahrami Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Aliakbar Rahbarimanesh
- Department of Pediatric Infection Disease, Bahrami Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Leila Khedmat
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Anahita Izadi
- Department of Pediatric Infection Disease, Bahrami Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Emr BM, Alcamo AM, Carcillo JA, Aneja RK, Mollen KP. Pediatric Sepsis Update: How Are Children Different? Surg Infect (Larchmt) 2018; 19:176-183. [PMID: 29394150 DOI: 10.1089/sur.2017.316] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Although there are some commonalities between pediatric and adult sepsis, there are important differences in pathophysiology, clinical presentation, and therapeutic approaches. The recognition and diagnosis of sepsis is a significant challenge in pediatric patients as vital sign aberrations and examination findings are often subtle as compared to those observed in adults. Gaps in knowledge that have been studied in depth in adult sepsis are still being investigated in pediatric patients such as best practices in ventilation, invasive monitoring, and resuscitation. DISCUSSION In this review, we address key differences in the etiology, presentation, resuscitation, and outcomes of sepsis in children compared with adults.
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Affiliation(s)
- Bryanna M Emr
- 1 Department of Surgery, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,2 Division of Pediatric Surgery, Children's Hospital of Pittsburgh of UPMC , Pittsburgh, Pennsylvania
| | - Alicia M Alcamo
- 3 Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Joseph A Carcillo
- 3 Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Rajesh K Aneja
- 3 Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Kevin P Mollen
- 1 Department of Surgery, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,2 Division of Pediatric Surgery, Children's Hospital of Pittsburgh of UPMC , Pittsburgh, Pennsylvania
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16
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A Quality Improvement Collaborative for Pediatric Sepsis: Lessons Learned. Pediatr Qual Saf 2017; 3:e051. [PMID: 30229187 PMCID: PMC6132697 DOI: 10.1097/pq9.0000000000000051] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 11/16/2017] [Indexed: 01/20/2023] Open
Abstract
Background: Sepsis is a leading cause of morbidity and mortality in children worldwide. Barriers exist for timely recognition and management in emergency care settings. This 1-year quality improvement collaborative sought to reduce mortality from sepsis. Methods: Fifteen hospitals participated initially. We included children with a spectrum of illness from sepsis to septic shock. The intervention bundle focused on recognition, escalation of care, and the first hour of resuscitation. We conducted monthly learning sessions and disseminated data reports of site-specific and aggregated metrics to drive rapid cycle improvement. Results: Seven sites contributed enough data to be analyzed. Of the 1,173 pediatric patients in the total cohort, 506 presented with severe sepsis/septic shock. Quarterly data demonstrated a mean improvement in initial clinical assessment from 46% to 60% (P < 0.001) and in adherence to the administration of first fluid bolus within 15 minutes from 38% to 46% (P < 0.015). There was no statistically significant improvement in other process metrics. There was no statistically significant improvement in mortality for the total cohort (sepsis to septic shock) or either of the subgroups in either 3- or 30-day mortality. Conclusions: A quality improvement collaborative focused on improving timely recognition and management of pediatric sepsis to septic shock led to some process improvements but did not show improvement in mortality. Future national efforts should standardize definitions and processes of care for sepsis to septic shock, including the identification of a “time zero” for measuring the timeliness of treatment.
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Hébert A, Boucher MP, Guimont C, Weiss M. Effect of measuring vital signs on recognition and treatment of septic children. Paediatr Child Health 2017; 22:13-16. [PMID: 29483789 DOI: 10.1093/pch/pxw003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background and objectives A majority of children presenting with sepsis do not receive adequate fluid resuscitation and have a delay in antibiotic administration despite recommendations from the Surviving Sepsis Campaign. The objective of this study was to evaluate the association of measuring a complete set of five vital signs in the emergency department (ED) with recognition and treatment of septic children presenting to the ED. Methods Records of 218 patients aged 1 month to 17 years treated between February 2011 and December 2011 in a single academic centre with clinical criteria of sepsis, severe sepsis or septic shock were retrospectively evaluated. The presence or absence of complete vital signs was analyzed in relation to timing of fluid resuscitation, and if antibiotics were given in the first hour of medical evaluation. Results Seventy-six per cent of children who had all five vital signs measured in the ED received fluid resuscitation in the first hour after medical evaluation as opposed to 61% of those who had an incomplete set of vital signs (P<0.04). Twenty per cent of children who had all five vital signs measured received antibiotics in the first hour as opposed to 9% in children who had fewer vital signs measured (P<0.02). Conclusion In our study population, the measurement of all vital signs in the ED, including blood pressure, was associated with faster administration of antibiotics and improved compliance with existing fluid bolus recommendations, which may have been the result of better recognition of sepsis in children through vital signs measurement.
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Affiliation(s)
- Audrey Hébert
- Department of Pediatrics, Centre Mère-Enfant Soleil, CHU de Québec, Université Laval, Quebec City, Québec
| | - Marie-Pier Boucher
- Department of Emergency Medicine, Centre Mère-Enfant Soleil, CHU de Québec, Université Laval, Quebec City, Québec
| | - Chantal Guimont
- Department of Emergency Medicine, Centre Mère-Enfant Soleil, CHU de Québec, Université Laval, Quebec City, Québec
| | - Matthew Weiss
- Department of Pediatrics, Centre Mère-Enfant Soleil, CHU de Québec, Université Laval, Quebec City, Québec
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18
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Immunomodulation in Critical Illness: The Quest Continues. Pediatr Crit Care Med 2017; 18:190-191. [PMID: 28157794 DOI: 10.1097/pcc.0000000000001006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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McAvoy JC, Khurana A. Getting Burned by Lactic Acid. Hosp Pediatr 2016; 6:558-9. [PMID: 27488209 DOI: 10.1542/hpeds.2016-0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | - Ashna Khurana
- Santa Clara Valley Medical Center, San Jose, California
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20
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Świerzko AS, Szala-Poździej A, Kilpatrick DC, Sobociński M, Chojnacka K, Sokołowska A, Michalski M, Mazerant K, Jensenius JC, Matsushita M, Krajewski WR, Szczapa J, Bąk-Romaniszyn L, Zeman K, Cedzyński M. Components of the lectin pathway of complement activation in paediatric patients of intensive care units. Immunobiology 2016; 221:657-69. [PMID: 26850322 DOI: 10.1016/j.imbio.2016.01.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 12/18/2015] [Accepted: 01/12/2016] [Indexed: 11/18/2022]
Abstract
Infections are a major cause of childhood mortality. We investigated components of the lectin pathway of complement activation in the context of sepsis at both genetic and protein levels in neonates, infants and older children. Major components of the lectin pathway and two genes for Toll-like receptors were studied in 87 neonates with confirmed sepsis and compared with 40 babies with infections who did not develop sepsis (disease controls) and 273 infection-free neonatal controls. A second cohort comprised 47 older children with sepsis and 87 controls. Low MBL-conferring genotypes (LXA/O+O/O) were more frequent in sepsis patients than in healthy controls but no significant differences in the frequency of SNPs of other lectin pathway genes (FCN1, FCN2, FCN3, MASP1/3, MASP2) or TLR receptor genes (TLR2, TLR4) were found. One case of primary MASP-2 deficiency was found among healthy pre-terms and one neonate suffering from SIRS was heterozygous for the rare FCN1 gene mutation, +6658 G>A. Generally, sepsis was associated with low serum MBL and low ficolin-2 concentrations on admission. Among neonates, ficolin-1 and MASP-2 levels were elevated in sepsis relative to healthy, but not disease, controls. Unlike neonates, ficolin-3 and MASP-2 levels were lower in older patients than in healthy controls while no difference was found for ficolin-1. With the possible exception of MBL, inherited lectin pathway insufficiencies do not seem to predispose to sepsis, rather changes in protein concentrations reflect alterations in disease course.
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Affiliation(s)
- Anna S Świerzko
- Laboratory of Immunobiology of Infections, Institute of Medical Biology, Polish Academy of Sciences, Lodowa 106, 93-232 Lodz, Poland
| | - Agnieszka Szala-Poździej
- Laboratory of Immunobiology of Infections, Institute of Medical Biology, Polish Academy of Sciences, Lodowa 106, 93-232 Lodz, Poland
| | - David C Kilpatrick
- Scottish National Blood Transfusion Service, National Science Laboratory, Ellen's Glen Road, Edinburgh, EH17 7QT Scotland, UK
| | - Michał Sobociński
- Department of Anesthesiology and Intensive Therapy, Polish Mother's Memorial Hospital Research Institute, Rzgowska 281/289, 93-338 Lodz, Poland
| | - Karolina Chojnacka
- Department of Newborns Infectious Diseases, Poznan University of Medical Sciences, Polna 33, 60-533 Poznan, Poland
| | - Anna Sokołowska
- Laboratory of Immunobiology of Infections, Institute of Medical Biology, Polish Academy of Sciences, Lodowa 106, 93-232 Lodz, Poland
| | - Mateusz Michalski
- Laboratory of Immunobiology of Infections, Institute of Medical Biology, Polish Academy of Sciences, Lodowa 106, 93-232 Lodz, Poland; Institute of Microbiology, Biotechnology and Immunology, University of Lodz, Banacha 12/16, 90-237 Lodz, Poland
| | - Karolina Mazerant
- Laboratory of Immunobiology of Infections, Institute of Medical Biology, Polish Academy of Sciences, Lodowa 106, 93-232 Lodz, Poland
| | - Jens C Jensenius
- Department of Biomedicine, Aarhus University, Vennellyst Boulevard 4, Aarhus DK-8000, Denmark
| | - Misao Matsushita
- Department of Applied Biochemistry, Tokai University, 4-1-1 Kitakaname, Hiratsuka-shi, Kanagawa 259-1292, Japan
| | - Wojciech R Krajewski
- Department of Anesthesiology and Intensive Therapy, Polish Mother's Memorial Hospital Research Institute, Rzgowska 281/289, 93-338 Lodz, Poland
| | - Jerzy Szczapa
- Department of Newborns Infectious Diseases, Poznan University of Medical Sciences, Polna 33, 60-533 Poznan, Poland
| | - Leokadia Bąk-Romaniszyn
- Department of Nutrition in Digestive Tract Diseases, Medical University of Lodz, Rzgowska 281/289, 93-338 Lodz, Poland
| | - Krzysztof Zeman
- Department of Paediatrics, Immunology and Nephrology, Polish Mother's Memorial Hospital Research Institute, Rzgowska 281/289, 93-338 Lodz, Poland
| | - Maciej Cedzyński
- Laboratory of Immunobiology of Infections, Institute of Medical Biology, Polish Academy of Sciences, Lodowa 106, 93-232 Lodz, Poland.
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21
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Balamuth F, Alpern ER, Grundmeier RW, Chilutti M, Weiss SL, Fitzgerald JC, Hayes K, Bilker W, Lautenbach E. Comparison of Two Sepsis Recognition Methods in a Pediatric Emergency Department. Acad Emerg Med 2015; 22:1298-306. [PMID: 26474032 PMCID: PMC4639443 DOI: 10.1111/acem.12814] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 06/26/2015] [Accepted: 06/30/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVES The objective was to compare the effectiveness of physician judgment and an electronic algorithmic alert to identify pediatric patients with severe sepsis/septic shock in a pediatric emergency department (ED). METHODS This was an observational cohort study of patients older than 56 days with fever or hypothermia. All patients were evaluated for potential sepsis in real time by the ED clinical team. An electronic algorithmic alert was retrospectively applied to identify patients with potential sepsis independent of physician judgment. The primary outcome was the proportion of patients correctly identified with severe sepsis/septic shock defined by consensus criteria. Test characteristics were determined and receiver operating characteristic (ROC) curves were compared. RESULTS Of 19,524 eligible patient visits, 88 patients developed consensus-confirmed severe sepsis or septic shock. Physician judgment identified 159 and the algorithmic alert identified 3,301 patients with potential sepsis. Physician judgment had sensitivity of 72.7% (95% confidence interval [CI] = 72.1% to 73.4%) and specificity of 99.5% (95% CI = 99.4% to 99.6%); the algorithmic alert had sensitivity of 92.1% (95% CI = 91.7% to 92.4%) and specificity of 83.4% (95% CI = 82.9% to 83.9%) for severe sepsis/septic shock. There was no significant difference in the area under the ROC curve for physician judgment (0.86, 95% CI = 0.81 to 0.91) or the algorithm (0.88, 95% CI = 0.85 to 0.91; p = 0.54). A combination method using either positive physician judgment or an algorithmic alert improved sensitivity to 96.6% and specificity to 83.3%. A sequential approach, in which positive identification by the algorithmic alert was then confirmed by physician judgment, achieved 68.2% sensitivity and 99.6% specificity. Positive and negative predictive values for physician judgment versus algorithmic alert were 40.3% versus 2.5% and 99.88% versus 99.96%, respectively. CONCLUSIONS The electronic algorithmic alert was more sensitive but less specific than physician judgment for recognition of pediatric severe sepsis and septic shock. These findings can help to guide institutions in selecting pediatric sepsis recognition methods based on institutional needs and priorities.
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Affiliation(s)
- Fran Balamuth
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Division of Emergency Medicine and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Elizabeth R Alpern
- Department of Pediatrics, Northwestern University Feinberg School of Medicine and Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Robert W Grundmeier
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Biomedical Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Marianne Chilutti
- Center for Biomedical Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Scott L Weiss
- Department of Anesthesia and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Division of Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Julie C Fitzgerald
- Department of Anesthesia and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Division of Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Katie Hayes
- Division of Emergency Medicine and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Warren Bilker
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ebbing Lautenbach
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Medicine, Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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