Shock Index in the early assessment of febrile children at the emergency department: a prospective multicentre study

The Shock Index among Children Presenting to the Emergency Department: Analysis of Nationally Representative Sample

BACKGROUND

The Shock Index (SI) is emerging as a potentially useful measure among children with injury or suspected sepsis.

OBJECTIVE

The aim of this study was to evaluate the distribution of the SI and evaluate its association with clinical outcomes among all children presenting to the emergency department (ED).

METHODS

A complex survey of nonfederal U.S. ED encounters from 2016 through 2021 was analyzed. Among children, the Pediatric Age-Adjusted Shock Index (SIPA), Pediatric Shock Index (PSI), and the Temperature- and Age-Adjusted Shock Index (TAMSI) were analyzed. The association of these criteria with disposition, acuity, medication administration, diagnoses and procedures was analyzed.

RESULTS

A survey-weighted 81.5 million ED visits were included for children aged 4-16 years and 117.2 million visits were included for children aged 1-12 years. SI could be calculated for 78.6% of patients aged 4-16 years and 57.9% of patients aged 1-12 years. An abnormal SI was present in 15.9%, 11.1%, and 31.7% when using the SIPA, PSI, and TAMSI, respectively. With all criteria, an elevated SI was associated with greater hospitalization. The SIPA and PSI were associated with triage acuity. All criteria were associated with medical interventions, including provision of IV fluids and acquisition of blood cultures.

CONCLUSIONS

An elevated SI is indicative of greater resource utilization needs among children in the ED. When using any criteria, an elevated SI was associated with clinically important outcomes. Further research is required to evaluate the distribution of the SI in children and to investigate its potential role within existing triage algorithms for children in the ED.

Postpartum acute adrenal insufficiency of early-onset Sheehan syndrome: A case series study in a single center

AIM

To identify the symptoms and relevant factors associated with acute adrenal insufficiency of early-onset Sheehan syndrome.

METHODS

We retrospectively reviewed the charts of 125 women admitted to our intensive care unit because of postpartum hemorrhage between January 2011 and December 2021. Three women developed acute adrenal insufficiency. We investigated the total blood loss, shock status, consciousness level upon arrival, and intensive care provided to the women. We also analyzed the symptoms and laboratory data that led to the diagnosis of acute adrenal insufficiency. Continuous variables were presented by median (minimum-maximum).

RESULTS

The medians and ranges of age, total blood loss, and shock index [heart rate/systolic blood pressure] on admission were 33.1 (17.2-45.3) years, 3351 (595-20 260) g, and 0.94 (0.55-2.94), respectively. Seven women were older than 40 years, 28 experienced >5000 g blood loss, 17 had shock index >1.5, 27 had impaired consciousness upon arrival, and 15 underwent hysterectomy. Women who developed acute adrenal insufficiency were <40 years old and had a bleeding volume of over 5000 g, impaired consciousness upon arrival, and had undergone hysterectomy. They had experienced lactation failure, presented with hyponatremia-related symptoms on postpartum days 8-9, experienced general malaise, headache, and impaired consciousness, and showed severe hyponatremia.

CONCLUSIONS

Massive postpartum hemorrhage over 5000 g, impaired consciousness upon arrival, and hysterectomy as a hemostatic measure were relevant factors associated with acute adrenal insufficiency of early-onset Sheehan syndrome. Hyponatremia-related symptoms occurring after lactation failure are indicative of the onset of acute adrenal insufficiency.

Mid-Regional Pro-Adrenomedullin in Combination With Pediatric Early Warning Scores for Risk Stratification of Febrile Children Presenting to the Emergency Department: Secondary Analysis of a Nonprespecified United Kingdom Cohort Study

OBJECTIVES

Current sepsis guidelines do not provide good risk stratification of subgroups in whom prompt IV antibiotics and fluid resuscitation might of benefit. We evaluated the utility of mid-regional pro-adrenomedullin (MR-proADM) in identification of patient subgroups at risk of requiring PICU or high-dependency unit (HDU) admission or fluid resuscitation.

DESIGN

Secondary, nonprespecified analysis of prospectively collected dataset.

SETTING

Pediatric Emergency Department in a United Kingdom tertiary center.

PATIENTS

Children less than 16 years old presenting with fever and clinical indication for venous blood sampling ( n = 1,183).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Primary outcome measures were PICU/HDU admission or administration of fluid resuscitation, with a secondary outcome of definite or probable bacterial infection. Biomarkers were measured on stored plasma samples and children phenotyped into bacterial and viral groups using a previously published algorithm. Of the 1,183 cases, 146 children (12.3%) required fluids, 48 (4.1%) were admitted to the PICU/HDU, and 244 (20.6%) had definite or probable bacterial infection. Area under the receiver operating characteristic (AUC) was used to assess performance. MR-proADM better predicted fluid resuscitation (AUC, 0.73; 95% CI, 0.67-0.78), than both procalcitonin (AUC, 0.65; 95% CI, 0.59-0.71) and Pediatric Early Warning Score (PEWS: AUC, 0.62; 95% CI, 0.56-0.67). PEWS alone showed good accuracy for PICU/HDU admission 0.83 (0.78-0.89). Patient subgroups with high MR-proADM (≥ 0.7 nmol/L) and high procalcitonin (≥ 0.5 ng/mL) had increased association with PICU/HDU admission, fluid resuscitation, and bacterial infection compared with subgroups with low MR-proADM (< 0.7 nmol/L). For children with procalcitonin less than 0.5 ng/mL, high MR-proADM improved stratification for fluid resuscitation only.

CONCLUSIONS

High MR-proADM and high procalcitonin were associated with increased likelihood of subsequent disease progression. Incorporating MR-proADM into clinical risk stratification may be useful in clinician decision-making regarding initiation of IV antibiotics, fluid resuscitation, and escalation to PICU/HDU admission.

Febrile children with comorbidities at the emergency department - a multicentre observational study

We aimed to describe characteristics and management of children with comorbidities attending European emergency departments (EDs) with fever. MOFICHE (Management and Outcome of Fever in children in Europe) is a prospective multicentre study (12 European EDs, 8 countries). Febrile children with comorbidities were compared to those without in terms of patient characteristics, markers of disease severity, management, and diagnosis. Comorbidity was defined as a chronic underlying condition that is expected to last > 1 year. We performed multivariable logistic regression analysis, displaying adjusted odds ratios (aOR), adjusting for patient characteristics. We included 38,110 patients, of whom 5906 (16%) had comorbidities. Most common comorbidities were pulmonary, neurologic, or prematurity. Patients with comorbidities more often were ill appearing (20 versus 16%, p < 0.001), had an ED-Paediatric Early Warning Score of > 15 (22 versus 12%, p < 0.001), or a C-reactive protein > 60 mg/l (aOR 1.4 (95%CI 1.3-1.6)). They more often required life-saving interventions (aOR 2.7, 95% CI 2.2-3.3), were treated with intravenous antibiotics (aOR 2.3, 95%CI 2.1-2.5), and were admitted to the ward (aOR 2.2, 95%CI 2.1-2.4) or paediatric intensive care unit (PICU) (aOR 5.5, 95% CI 3.8-7.9). They were more often diagnosed with serious bacterial infections (aOR 1.8, 95%CI 1.7-2.0), including sepsis/meningitis (aOR 4.6, 95%CI 3.2-6.7). Children most at risk for sepsis/meningitis were children with malignancy/immunodeficiency (aOR 14.5, 8.5-24.8), while children with psychomotor delay/neurological disease were most at risk for life-saving interventions (aOR 5.3, 4.1-6.9) or PICU admission (aOR 9.7, 6.1-15.5).

CONCLUSIONS

Our data show how children with comorbidities are a population at risk, as they more often are diagnosed with bacterial infections and more often require PICU admission and life-saving interventions.

WHAT IS KNOWN

• While children with comorbidity constitute a large part of ED frequent flyers, they are often excluded from studies.

WHAT IS NEW

• Children with comorbidities in general are more ill upon presentation than children without comorbidities. • Children with comorbidities form a heterogeneous group; specific subgroups have an increased risk for invasive bacterial infections, while others have an increased risk of invasive interventions such as PICU admission, regardless of the cause of the fever.