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Scott HF, Lindberg DM, Brackman S, McGonagle E, Leonard JE, Adelgais K, Bajaj L, Dillon M, Kempe A. Pediatric Sepsis in General Emergency Departments: Association Between Pediatric Sepsis Case Volume, Care Quality, and Outcome. Ann Emerg Med 2024; 83:318-326. [PMID: 38069968 PMCID: PMC10960690 DOI: 10.1016/j.annemergmed.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 10/23/2023] [Accepted: 10/26/2023] [Indexed: 02/29/2024]
Abstract
STUDY OBJECTIVE To assess whether a general emergency department's (ED) annual pediatric sepsis volume increases the odds of delivering care concordant with Surviving Sepsis pediatric guidelines. METHODS A retrospective cohort study of children <18 years with sepsis presenting to 29 general EDs. Emergency department and hospital data were abstracted from the medical records of 2 large health care systems, including all hospitals to which children were transferred. Guideline-concordant care was defined as intravenous antibiotics within 3 hours, intravenous fluid bolus within 3 hours, and lactate measured. The association between annual ED pediatric sepsis encounters and the probability of receiving guideline-concordant care was assessed. RESULTS We included 1,527 ED encounters between January 1, 2015, and September 30, 2021. Three hundred and one (19%) occurred in 25 EDs with <10 pediatric sepsis encounters annually, 466 (31%) in 3 EDs with 11 to 100 pediatric sepsis encounters annually, and 760 (50%) in an ED with more than 100 pediatric sepsis encounters annually. Care was concordant in 627 (41.1%) encounters. In multivariable analysis, annual pediatric sepsis volume was minimally associated with the probability of guideline-concordant care (odds ratio 1.002 [95% confidence interval 1.001 to 1.00]). Care concordance increased from 23.1% in 2015 to 52.8% in 2021. CONCLUSION Guideline-concordant sepsis care was delivered in 41% of pediatric sepsis cases in general EDs, and annual ED pediatric sepsis encounters had minimal association with the odds of concordant care. Care concordance improved over time. This study suggests that factors other than pediatric sepsis volume are important in driving care quality and identifying drivers of improvement is important for children first treated in general EDs.
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Affiliation(s)
- Halden F Scott
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado, Aurora, CO.
| | - Daniel M Lindberg
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Savannah Brackman
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Erin McGonagle
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Jan E Leonard
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Kathleen Adelgais
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Lalit Bajaj
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Mairead Dillon
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Allison Kempe
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado, Aurora, CO
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Sanchez-Pinto LN, Bennett TD, DeWitt PE, Russell S, Rebull MN, Martin B, Akech S, Albers DJ, Alpern ER, Balamuth F, Bembea M, Chisti MJ, Evans I, Horvat CM, Jaramillo-Bustamante JC, Kissoon N, Menon K, Scott HF, Weiss SL, Wiens MO, Zimmerman JJ, Argent AC, Sorce LR, Schlapbach LJ, Watson RS. Development and Validation of the Phoenix Criteria for Pediatric Sepsis and Septic Shock. JAMA 2024; 331:675-686. [PMID: 38245897 PMCID: PMC10900964 DOI: 10.1001/jama.2024.0196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/05/2024] [Indexed: 01/23/2024]
Abstract
Importance The Society of Critical Care Medicine Pediatric Sepsis Definition Task Force sought to develop and validate new clinical criteria for pediatric sepsis and septic shock using measures of organ dysfunction through a data-driven approach. Objective To derive and validate novel criteria for pediatric sepsis and septic shock across differently resourced settings. Design, Setting, and Participants Multicenter, international, retrospective cohort study in 10 health systems in the US, Colombia, Bangladesh, China, and Kenya, 3 of which were used as external validation sites. Data were collected from emergency and inpatient encounters for children (aged <18 years) from 2010 to 2019: 3 049 699 in the development (including derivation and internal validation) set and 581 317 in the external validation set. Exposure Stacked regression models to predict mortality in children with suspected infection were derived and validated using the best-performing organ dysfunction subscores from 8 existing scores. The final model was then translated into an integer-based score used to establish binary criteria for sepsis and septic shock. Main Outcomes and Measures The primary outcome for all analyses was in-hospital mortality. Model- and integer-based score performance measures included the area under the precision recall curve (AUPRC; primary) and area under the receiver operating characteristic curve (AUROC; secondary). For binary criteria, primary performance measures were positive predictive value and sensitivity. Results Among the 172 984 children with suspected infection in the first 24 hours (development set; 1.2% mortality), a 4-organ-system model performed best. The integer version of that model, the Phoenix Sepsis Score, had AUPRCs of 0.23 to 0.38 (95% CI range, 0.20-0.39) and AUROCs of 0.71 to 0.92 (95% CI range, 0.70-0.92) to predict mortality in the validation sets. Using a Phoenix Sepsis Score of 2 points or higher in children with suspected infection as criteria for sepsis and sepsis plus 1 or more cardiovascular point as criteria for septic shock resulted in a higher positive predictive value and higher or similar sensitivity compared with the 2005 International Pediatric Sepsis Consensus Conference (IPSCC) criteria across differently resourced settings. Conclusions and Relevance The novel Phoenix sepsis criteria, which were derived and validated using data from higher- and lower-resource settings, had improved performance for the diagnosis of pediatric sepsis and septic shock compared with the existing IPSCC criteria.
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Affiliation(s)
- L. Nelson Sanchez-Pinto
- Departments of Pediatrics (Critical Care) and Preventive Medicine (Health and Biomedical Informatics), Northwestern University Feinberg School of Medicine, and Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Tellen D. Bennett
- Departments of Biomedical Informatics and Pediatrics (Critical Care Medicine), University of Colorado School of Medicine, and Children’s Hospital Colorado, Aurora
| | - Peter E. DeWitt
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora
| | - Seth Russell
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora
| | - Margaret N. Rebull
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora
| | - Blake Martin
- Departments of Biomedical Informatics and Pediatrics (Critical Care Medicine), University of Colorado School of Medicine, and Children’s Hospital Colorado, Aurora
| | - Samuel Akech
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme, Nairobi, Kenya
| | - David J. Albers
- Departments of Biomedical Informatics, Bioengineering, Biostatistics, and Informatics, University of Colorado School of Medicine, Aurora
- Department of Biomedical Informatics, Columbia University, New York, New York
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago, and Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Fran Balamuth
- Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine and Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia
| | - Melania Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mohammod Jobayer Chisti
- Intensive Care Unit, Dhaka Hospital, Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Idris Evans
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Christopher M. Horvat
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Juan Camilo Jaramillo-Bustamante
- Pediatric Intensive Care Unit, Hospital General de Medellín Luz Castro de Gutiérrez and Hospital Pablo Tobón Uribe, and Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Medellín, Colombia
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Kusum Menon
- Department of Pediatrics, Children’s Hospital of Eastern Ontario and University of Ottawa, Ottawa, Canada
| | - Halden F. Scott
- Department of Pediatrics (Pediatric Emergency Medicine), University of Colorado School of Medicine, and Children’s Hospital Colorado, Aurora
| | - Scott L. Weiss
- Division of Critical Care, Department of Pediatrics, Nemours Children’s Health, Wilmington, Delaware
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Matthew O. Wiens
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Institute for Global Health, BC Children’s Hospital, Vancouver, British Columbia, Canada
- Walimu, Kampala, Uganda
| | - Jerry J. Zimmerman
- Seattle Children’s Hospital and Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Andrew C. Argent
- Paediatrics and Child Health, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Lauren R. Sorce
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, and Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Luregn J. Schlapbach
- Department of Intensive Care and Neonatology, Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, Zurich, Switzerland
- Child Health Research Centre, The University of Queensland, Brisbane, Australia
| | - R. Scott Watson
- Department of Pediatrics, University of Washington, and Center for Child Health, Behavior, and Development and Pediatric Critical Care, Seattle Children’s Hospital, Seattle
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Schlapbach LJ, Watson RS, Sorce LR, Argent AC, Menon K, Hall MW, Akech S, Albers DJ, Alpern ER, Balamuth F, Bembea M, Biban P, Carrol ED, Chiotos K, Chisti MJ, DeWitt PE, Evans I, Flauzino de Oliveira C, Horvat CM, Inwald D, Ishimine P, Jaramillo-Bustamante JC, Levin M, Lodha R, Martin B, Nadel S, Nakagawa S, Peters MJ, Randolph AG, Ranjit S, Rebull MN, Russell S, Scott HF, de Souza DC, Tissieres P, Weiss SL, Wiens MO, Wynn JL, Kissoon N, Zimmerman JJ, Sanchez-Pinto LN, Bennett TD. International Consensus Criteria for Pediatric Sepsis and Septic Shock. JAMA 2024; 331:665-674. [PMID: 38245889 PMCID: PMC10900966 DOI: 10.1001/jama.2024.0179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/04/2024] [Indexed: 01/23/2024]
Abstract
Importance Sepsis is a leading cause of death among children worldwide. Current pediatric-specific criteria for sepsis were published in 2005 based on expert opinion. In 2016, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defined sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, but it excluded children. Objective To update and evaluate criteria for sepsis and septic shock in children. Evidence Review The Society of Critical Care Medicine (SCCM) convened a task force of 35 pediatric experts in critical care, emergency medicine, infectious diseases, general pediatrics, nursing, public health, and neonatology from 6 continents. Using evidence from an international survey, systematic review and meta-analysis, and a new organ dysfunction score developed based on more than 3 million electronic health record encounters from 10 sites on 4 continents, a modified Delphi consensus process was employed to develop criteria. Findings Based on survey data, most pediatric clinicians used sepsis to refer to infection with life-threatening organ dysfunction, which differed from prior pediatric sepsis criteria that used systemic inflammatory response syndrome (SIRS) criteria, which have poor predictive properties, and included the redundant term, severe sepsis. The SCCM task force recommends that sepsis in children be identified by a Phoenix Sepsis Score of at least 2 points in children with suspected infection, which indicates potentially life-threatening dysfunction of the respiratory, cardiovascular, coagulation, and/or neurological systems. Children with a Phoenix Sepsis Score of at least 2 points had in-hospital mortality of 7.1% in higher-resource settings and 28.5% in lower-resource settings, more than 8 times that of children with suspected infection not meeting these criteria. Mortality was higher in children who had organ dysfunction in at least 1 of 4-respiratory, cardiovascular, coagulation, and/or neurological-organ systems that was not the primary site of infection. Septic shock was defined as children with sepsis who had cardiovascular dysfunction, indicated by at least 1 cardiovascular point in the Phoenix Sepsis Score, which included severe hypotension for age, blood lactate exceeding 5 mmol/L, or need for vasoactive medication. Children with septic shock had an in-hospital mortality rate of 10.8% and 33.5% in higher- and lower-resource settings, respectively. Conclusions and Relevance The Phoenix sepsis criteria for sepsis and septic shock in children were derived and validated by the international SCCM Pediatric Sepsis Definition Task Force using a large international database and survey, systematic review and meta-analysis, and modified Delphi consensus approach. A Phoenix Sepsis Score of at least 2 identified potentially life-threatening organ dysfunction in children younger than 18 years with infection, and its use has the potential to improve clinical care, epidemiological assessment, and research in pediatric sepsis and septic shock around the world.
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Affiliation(s)
- Luregn J. Schlapbach
- Department of Intensive Care and Neonatology, and Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, Zurich, Switzerland
- Child Health Research Centre, University of Queensland, Brisbane, Australia
| | - R. Scott Watson
- Department of Pediatrics, University of Washington, Seattle
- Seattle Children’s Research Institute and Pediatric Critical Care, Seattle Children’s, Seattle, Washington
| | - Lauren R. Sorce
- Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andrew C. Argent
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- University of Cape Town, Cape Town, South Africa
| | - Kusum Menon
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Canada
- University of Ottawa, Ontario, Canada
| | - Mark W. Hall
- Division of Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Samuel Akech
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme, Nairobi, Kenya
| | - David J. Albers
- Departments of Biomedical Informatics, Bioengineering, Biostatistics and Informatics, University of Colorado School of Medicine, Aurora
- Department of Biomedical Informatics, Columbia University, New York, New York
| | - Elizabeth R. Alpern
- Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
- Department of Pediatrics, Division of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Fran Balamuth
- Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Melania Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Paolo Biban
- Pediatric Intensive Care Unit, Verona University Hospital, Verona, Italy
| | - Enitan D. Carrol
- University of Liverpool, Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, Liverpool, United Kingdom
| | - Kathleen Chiotos
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Divisions of Critical Care Medicine and Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mohammod Jobayer Chisti
- Intensive Care Unit, Dhaka Hospital, Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Peter E. DeWitt
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora
| | - Idris Evans
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania
| | - Cláudio Flauzino de Oliveira
- AMIB–Associação de Medicina Intensiva Brasileira, São Paulo, Brazil
- LASI–Latin American Institute of Sepsis, São Paulo, Brazil
| | - Christopher M. Horvat
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania
| | - David Inwald
- Paediatric Intensive Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Paul Ishimine
- Departments of Emergency Medicine and Pediatrics, University of California, San Diego School of Medicine, La Jolla
| | - Juan Camilo Jaramillo-Bustamante
- PICU Hospital General de Medellín “Luz Castro de Gutiérrez” and Hospital Pablo Tobón Uribe, Medellín, Colombia
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network)
| | - Michael Levin
- Section of Paediatric Infectious Diseases, Department of Infectious Diseases, Imperial College London, London, United Kingdom
- Department of Paediatrics, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Blake Martin
- Departments of Biomedical Informatics and Pediatrics (Division of Critical Care Medicine), University of Colorado School of Medicine and Pediatric Intensive Care Unit, Children’s Hospital Colorado, Aurora
- Pediatric Intensive Care Unit, Children’s Hospital Colorado, Aurora
| | - Simon Nadel
- Paediatric Intensive Care, St Mary’s Hospital, London, United Kingdom
- Imperial College London, London, United Kingdom
| | - Satoshi Nakagawa
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Mark J. Peters
- University College London Great Ormond Street Institute of Child Health, London, United Kingdom
- Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, United Kingdom
| | - Adrienne G. Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Departments of Anaesthesia and Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Suchitra Ranjit
- Pediatric Intensive Care Unit, Apollo Children’s Hospital, Chennai, India
| | - Margaret N. Rebull
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora
| | - Seth Russell
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora
| | - Halden F. Scott
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora
- Emergency Department, Children’s Hospital Colorado, Aurora
| | - Daniela Carla de Souza
- LASI–Latin American Institute of Sepsis, São Paulo, Brazil
- Department of Pediatrics (PICU), Hospital Universitario of the University of São Paulo, São Paulo, Brazil
- Department of Pediatrics (PICU), Hospital Sírio Libanês, São Paulo, Brazil
| | - Pierre Tissieres
- Pediatric Intensive Care, AP-HP Paris Saclay University, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Scott L. Weiss
- Division of Critical Care, Department of Pediatrics, Nemours Children’s Health, Wilmington, Delaware
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Matthew O. Wiens
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Institute for Global Health, BC Children’s Hospital, Vancouver, Canada and Walimu, Uganda
| | - James L. Wynn
- Department of Pediatrics, University of Florida, Gainesville
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Jerry J. Zimmerman
- Department of Pediatrics, University of Washington, Seattle
- Seattle Children’s Research Institute and Pediatric Critical Care, Seattle Children’s, Seattle, Washington
| | - L. Nelson Sanchez-Pinto
- Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
- Department of Pediatrics, Division of Critical Care, and Department of Preventive Medicine, Division of Health & Biomedical Informatics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Tellen D. Bennett
- Departments of Biomedical Informatics and Pediatrics (Division of Critical Care Medicine), University of Colorado School of Medicine and Pediatric Intensive Care Unit, Children’s Hospital Colorado, Aurora
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De Castro GC, Slatnick LR, Shannon M, Zhao Z, Jackson K, Smith CM, Whitehurst D, Elliott C, Clark CC, Scott HF, Friedman DL, Demedis J, Esbenshade AJ. Impact of Time-to-Antibiotic Delivery in Pediatric Patients With Cancer Presenting With Febrile Neutropenia. JCO Oncol Pract 2024; 20:228-238. [PMID: 38127868 PMCID: PMC10911541 DOI: 10.1200/op.23.00583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/30/2023] [Accepted: 11/09/2023] [Indexed: 12/23/2023] Open
Abstract
PURPOSE Febrile neutropenia (FN) in pediatric patients with cancer can cause severe infections, and prompt antibiotics are warranted. Extrapolated from other populations, a time-to-antibiotic (TTA) metric of <60 minutes after medical center presentation was established, with compliance data factoring into pediatric oncology program national rankings. METHODS All FN episodes occurring at Vanderbilt Children's Hospital (2007-February 2022) and a sample of episodes from Colorado Children's Hospital (2012-2019) were abstracted, capturing TTA and clinical outcomes including major complications (intensive care unit [ICU] admission, vasopressors, intubation, or infection-related mortality). Odds ratios (ORs) were adjusted for age, treatment center, absolute neutrophil count, hypotension presence, stem-cell transplant status, and central line type. RESULTS A total of 2,349 episodes were identified from Vanderbilt (1,920) and Colorado (429). Only 0.6% (n = 14) episodes required immediate ICU management, with a median TTA of 28 minutes (IQR, 20-37). For the remaining patients, the median TTA was 56 minutes (IQR, 37-90), and 54.3% received antibiotics in <60 minutes. There were no significant associations between TTA (<60 or ≥60 minutes) and major complications (adjusted OR, 0.99 [95% CI, 0.62 to 1.59]; P = .98), and a TTA ≥60 minutes was not associated with any type of complication. Similarly, TTA, when evaluated as a continuous variable, was not associated with a major (OR, 0.99 [95% CI, 0.94 to 1.04]; P = .69) nor any other complication in adjusted analysis. CONCLUSION There is no clear evidence that a reduced TTA improves clinical outcomes in pediatric oncology FN and thus it should not be used as a primary quality measure.
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Affiliation(s)
| | - Leonora R. Slatnick
- Department of Pediatrics, Section of Pediatric Hematology/Oncology, University of Colorado Anschutz Medical Center, Children's Hospital Colorado, Aurora, CO
| | | | - Zhiguo Zhao
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Kasey Jackson
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Vanderbilt University Medical Center and the Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - Christine M. Smith
- Vanderbilt-Ingram Cancer Center, Nashville, TN
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Vanderbilt University Medical Center and the Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | | | - Claire Elliott
- Department of Pediatric Emergency Medicine, the Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - Chelsea C. Clark
- Department of Pediatric Emergency Medicine, the Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - Halden F. Scott
- Department of Pediatrics, Section of Pediatric Emergency Medicine, University of Colorado Anschutz Medical Center, Children's Hospital Colorado, Aurora, CO
| | - Debra L. Friedman
- Vanderbilt-Ingram Cancer Center, Nashville, TN
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Vanderbilt University Medical Center and the Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - Jenna Demedis
- Department of Pediatrics, Section of Pediatric Hematology/Oncology, University of Colorado Anschutz Medical Center, Children's Hospital Colorado, Aurora, CO
| | - Adam J. Esbenshade
- Vanderbilt-Ingram Cancer Center, Nashville, TN
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Vanderbilt University Medical Center and the Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
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Balamuth F, Scott HF. The Challenge of Identifying Sepsis in Children. Ann Emerg Med 2023; 82:503-504. [PMID: 37436345 DOI: 10.1016/j.annemergmed.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 05/24/2023] [Indexed: 07/13/2023]
Affiliation(s)
- Fran Balamuth
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Division of Pediatric Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Halden F Scott
- Department of Pediatrics, University of Colorado, Denver, CO; Division of Emergency Medicine, Children's Hospital Colorado, Aurora, CO
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Slatnick LR, Miller K, Scott HF, Loi M, Esbenshade AJ, Franklin A, Lee-Sherick AB. Serum lactate is associated with increased illness severity in immunocompromised pediatric hematology oncology patients presenting to the emergency department with fever. Front Oncol 2022; 12:990279. [PMID: 36276165 PMCID: PMC9583361 DOI: 10.3389/fonc.2022.990279] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 09/19/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction Determining which febrile pediatric hematology/oncology (PHO) patients will decompensate from severe infection is a significant challenge. Serum lactate is a well-established marker of illness severity in general adult and pediatric populations, however its utility in PHO patients is unclear given that chemotherapy, organ dysfunction, and cancer itself can alter lactate metabolism. In this retrospective analysis, we studied the association of initial serum lactate in febrile immunosuppressed PHO patients with illness severity, defined by the incidence of clinical deterioration events (CDE) and invasive bacterial infection (IBI) within 48 hours. Methods Receiver operating characteristic (ROC) curves were reported using initial lactate within two hours of arrival as the sole predictor for CDE and IBI within 48 hours. Using a generalized estimating equations (GEE) approach, the association of lactate with CDE and IBI within 48 hours was tested in univariate and multivariable analyses including covariates based on Quasi-likelihood under Independence Model Criterion (QIC). Additionally, the association of lactate with secondary outcomes (i.e., hospital length of stay (LOS), intensive care unit (PICU) admission, PICU LOS, non-invasive infection) was assessed. Results Among 897 encounters, 48 encounters had ≥1 CDE (5%), and 96 had ≥1 IBI (11%) within 48 hours. Elevated lactate was associated with increased CDE in univariate (OR 1.77, 95%CI: 1.48-2.12, p<0.001) and multivariable (OR 1.82, 95%CI: 1.43-2.32, p<0.001) analyses, longer hospitalization (OR 1.15, 95%CI: 1.07-1.24, p<0.001), increased PICU admission (OR 1.68, 95%CI: 1.41-2.0, p<0.001), and longer PICU LOS (OR 1.21, 95%CI: 1.04-1.4, p=0.01). Elevated lactate was associated with increased IBI in univariate (OR 1.40, 95%CI: 1.16-1.69, p<0.001) and multivariable (OR 1.49, 95%CI: 1.23-1.79, p<0.001) analyses. Lactate level was not significantly associated with increased odds of non-invasive infection (p=0.09). The QIC of the model was superior with lactate included for both CDE (305 vs. 325) and IBI (563 vs. 579). Conclusions These data demonstrated an independent association of elevated initial lactate level and increased illness severity in febrile PHO patients, suggesting that serum lactate could be incorporated into future risk stratification strategies for this population.
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Affiliation(s)
- Leonora Rose Slatnick
- Department of Pediatrics, Center for Cancer and Blood Disorders, University of Colorado Anschutz Medical Center, Children’s Hospital Colorado, Aurora, CO, United States
- *Correspondence: Leonora Rose Slatnick,
| | - Kristen Miller
- Department of Pediatrics, Center for Cancer and Blood Disorders, University of Colorado Anschutz Medical Center, Children’s Hospital Colorado, Aurora, CO, United States
| | - Halden F. Scott
- Department of Pediatrics, Section of Pediatric Emergency Medicine, University of Colorado Anschutz Medical Center, Children’s Hospital Colorado, Aurora, CO, United States
| | - Michele Loi
- Department of Pediatrics, Center for Cancer and Blood Disorders, University of Colorado Anschutz Medical Center, Children’s Hospital Colorado, Aurora, CO, United States
- Department of Pediatrics, Division of Critical Care Medicine, University of Colorado Anschutz Medical Center, Children’s Hospital Colorado, Aurora, CO, United States
| | - Adam J. Esbenshade
- Department of Pediatrics, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, TN, United States
| | - Anna Franklin
- Department of Pediatrics, Center for Cancer and Blood Disorders, University of Colorado Anschutz Medical Center, Children’s Hospital Colorado, Aurora, CO, United States
| | - Alisa B. Lee-Sherick
- Department of Pediatrics, Center for Cancer and Blood Disorders, University of Colorado Anschutz Medical Center, Children’s Hospital Colorado, Aurora, CO, United States
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Scott HF, Kempe A, Bajaj L, Lindberg DM, Dafoe A, Dorsey Holliman B. "These Are Our Kids": Qualitative Interviews With Clinical Leaders in General Emergency Departments on Motivations, Processes, and Guidelines in Pediatric Sepsis Care. Ann Emerg Med 2022; 80:347-357. [PMID: 35840434 PMCID: PMC9529081 DOI: 10.1016/j.annemergmed.2022.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/02/2022] [Accepted: 05/25/2022] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE Sepsis is a leading cause of pediatric death requiring emergency resuscitation. Most children with sepsis are treated in general emergency departments (EDs); however, research has focused on pediatric EDs. We sought to identify barriers and facilitators to pediatric sepsis care in general EDs, including care processes, the role of guidelines, and incentivized metrics. METHODS In this qualitative study, we conducted semistructured interviews with key informant physician and nurse leaders overseeing pediatric sepsis in general EDs in 2021, including medical directors, nurse managers, and quality coordinators. Interviews were audio-recorded, transcribed, and coded using deductive domains based on steps of sepsis care, pediatric readiness, and structural dynamics. Domains were analyzed across interviews in matrices, using thematic analysis within domains. RESULTS Twenty-one clinical leaders representing 26 hospitals, including trauma levels I to IV, were interviewed. The themes included the following: (1) motivation to improve pediatric sepsis care based on moral imperative and location; (2) need for actionable pediatric sepsis guidelines; (3) children's hospitals' role in education, protocols, transfer, and consultation; and (4) mixed feelings about reportable metrics, particularly in EDs with low pediatric volume. Sepsis care process challenges included diagnosis, intravenous access, and antibiotic delivery but varied among hospitals. CONCLUSION Leaders in general EDs were motivated to provide high-quality pediatric sepsis care but disagreed on whether reportable metrics would drive improvements. They universally sought direct support from their nearest children's hospitals and actionable guidelines. Efforts to address pediatric sepsis quality in general EDs should prioritize guideline design, responsive pediatric transfer and consultation systems, and locally specific process improvement.
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Affiliation(s)
- Halden F Scott
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Children's Hospital Colorado, Aurora, CO; Adult and Child Center for Outcomes Research and Delivery Science, Aurora, CO.
| | - Allison Kempe
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Children's Hospital Colorado, Aurora, CO; Adult and Child Center for Outcomes Research and Delivery Science, Aurora, CO
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Children's Hospital Colorado, Aurora, CO
| | - Daniel M Lindberg
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Ashley Dafoe
- Adult and Child Center for Outcomes Research and Delivery Science, Aurora, CO
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Balamuth F, Scott HF, Weiss SL, Webb M, Chamberlain JM, Bajaj L, Depinet H, Grundmeier RW, Campos D, Deakyne Davies SJ, Simon NJ, Cook LJ, Alpern ER. Validation of the Pediatric Sequential Organ Failure Assessment Score and Evaluation of Third International Consensus Definitions for Sepsis and Septic Shock Definitions in the Pediatric Emergency Department. JAMA Pediatr 2022; 176:672-678. [PMID: 35575803 PMCID: PMC9112137 DOI: 10.1001/jamapediatrics.2022.1301] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Pediatric sepsis definitions have evolved, and some have proposed using the measure used in adults to quantify organ dysfunction, a Sequential Organ Failure Assessment (SOFA) score of 2 or more in the setting of suspected infection. A pediatric adaptation of SOFA (pSOFA) showed excellent discrimination for mortality in critically ill children but has not been evaluated in an emergency department (ED) population. OBJECTIVE To delineate test characteristics of the pSOFA score for predicting in-hospital mortality among (1) all patients and (2) patients with suspected infection treated in pediatric EDs. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study took place from January 1, 2012, to January 31, 2020 in 9 US children's hospitals included in the Pediatric Emergency Care Applied Research Network (PECARN) Registry. The data was analyzed from February 1, 2020, to April 18, 2022. All ED visits for patients younger than 18 years were included. EXPOSURES ED pSOFA score was assigned by summing maximum pSOFA organ dysfunction components during ED stay (each 0-4 points). In the subset with suspected infection, visit meeting criteria for sepsis (suspected infection with a pSOFA score of 2 or more) and septic shock (suspected infection with vasoactive infusion and serum lactate level >18.0 mg/dL) were identified. MAIN OUTCOMES AND MEASURES Test characteristics of pSOFA scores of 2 or more during the ED stay for hospital mortality. RESULTS A total of 3 999 528 (female, 47.3%) ED visits were included. pSOFA scores ranged from 0 to 16, with 126 250 visits (3.2%) having a pSOFA score of 2 or more. pSOFA scores of 2 or more had sensitivity of 0.65 (95% CI, 0.62-0.67) and specificity of 0.97 (95% CI, 0.97-0.97), with negative predictive value of 1.0 (95% CI, 1.00-1.00) in predicting hospital mortality. Of 642 868 patients with suspected infection (16.1%), 42 992 (6.7%) met criteria for sepsis, and 374 (0.1%) met criteria for septic shock. Hospital mortality rates for suspected infection (599 502), sepsis (42 992), and septic shock (374) were 0.0%, 0.9%, and 8.0%, respectively. The pSOFA score had similar discrimination for hospital mortality in all ED visits (area under receiver operating characteristic curve, 0.81; 95% CI, 0.79-0.82) and the subset with suspected infection (area under receiver operating characteristic curve, 0.82; 95% CI, 0.80-0.84). CONCLUSIONS AND RELEVANCE In a large, multicenter study of pediatric ED visits, a pSOFA score of 2 or more was uncommon and associated with increased hospital mortality yet had poor sensitivity as a screening tool for hospital mortality. Conversely, children with a pSOFA score of 2 or less were at very low risk of death, with high specificity and negative predictive value. Among patients with suspected infection, patients with pSOFA-defined septic shock demonstrated the highest mortality.
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Affiliation(s)
- Fran Balamuth
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Scott L. Weiss
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | | | - Holly Depinet
- Cincinnnati Children’s Hospital and Medical Center, Cincinnati, Ohio
| | - Robert W. Grundmeier
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Diego Campos
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Martin B, DeWitt PE, Scott HF, Parker S, Bennett TD. Machine Learning Approach to Predicting Absence of Serious Bacterial Infection at PICU Admission. Hosp Pediatr 2022; 12:590-603. [PMID: 35634885 DOI: 10.1542/hpeds.2021-005998] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Serious bacterial infection (SBI) is common in the PICU. Antibiotics can mitigate associated morbidity and mortality but have associated adverse effects. Our objective is to develop machine learning models able to identify SBI-negative children and reduce unnecessary antibiotics. METHODS We developed models to predict SBI-negative status at PICU admission using vital sign, laboratory, and demographic variables. Children 3-months to 18-years-old admitted to our PICU, between 2011 and 2020, were included if evaluated for infection within 24-hours, stratified by documented antibiotic exposure in the 48-hours prior. Area under the receiver operating characteristic curve (AUROC) was the primary model accuracy measure; secondarily, we calculated the number of SBI-negative children subsequently provided antibiotics in the PICU identified as low-risk by each model. RESULTS A total of 15 074 children met inclusion criteria; 4788 (32%) received antibiotics before PICU admission. Of these antibiotic-exposed patients, 2325 of 4788 (49%) had an SBI. Of the 10 286 antibiotic-unexposed patients, 2356 of 10 286 (23%) had an SBI. In antibiotic-exposed children, a radial support vector machine model had the highest AUROC (0.80) for evaluating SBI, identifying 48 of 442 (11%) SBI-negative children provided antibiotics in the PICU who could have been spared a median 3.7 (interquartile range 0.9-9.0) antibiotic-days per patient. In antibiotic-unexposed children, a random forest model performed best, but was less accurate overall (AUROC 0.76), identifying 33 of 469 (7%) SBI-negative children provided antibiotics in the PICU who could have been spared 1.1 (interquartile range 0.9-3.7) antibiotic-days per patient. CONCLUSIONS Among children who received antibiotics before PICU admission, machine learning models can identify children at low risk of SBI and potentially reduce antibiotic exposure.
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Affiliation(s)
- Blake Martin
- Department of Pediatrics, Sections of Critical Care
- Children's Hospital Colorado, Aurora, Colorado
| | | | - Halden F Scott
- Emergency Medicine
- Children's Hospital Colorado, Aurora, Colorado
| | - Sarah Parker
- Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado
- Children's Hospital Colorado, Aurora, Colorado
| | - Tellen D Bennett
- Department of Pediatrics, Sections of Critical Care
- Informatics and Data Science
- Children's Hospital Colorado, Aurora, Colorado
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Eisenberg MA, Riggs R, Paul R, Balamuth F, Richardson T, DeSouza HG, Abbadesa MK, DeMartini TK, Frizzola M, Lane R, Lloyd J, Melendez E, Patankar N, Rutman L, Sebring A, Timmons Z, Scott HF. Association Between the First-Hour Intravenous Fluid Volume and Mortality in Pediatric Septic Shock. Ann Emerg Med 2022; 80:213-224. [DOI: 10.1016/j.annemergmed.2022.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/25/2022] [Accepted: 04/07/2022] [Indexed: 12/20/2022]
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Menon K, Schlapbach LJ, Akech S, Argent A, Biban P, Carrol ED, Chiotos K, Jobayer Chisti M, Evans IVR, Inwald DP, Ishimine P, Kissoon N, Lodha R, Nadel S, Oliveira CF, Peters M, Sadeghirad B, Scott HF, de Souza DC, Tissieres P, Watson RS, Wiens MO, Wynn JL, Zimmerman JJ, Sorce LR. Criteria for Pediatric Sepsis-A Systematic Review and Meta-Analysis by the Pediatric Sepsis Definition Taskforce. Crit Care Med 2022; 50:21-36. [PMID: 34612847 PMCID: PMC8670345 DOI: 10.1097/ccm.0000000000005294] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To determine the associations of demographic, clinical, laboratory, organ dysfunction, and illness severity variable values with: 1) sepsis, severe sepsis, or septic shock in children with infection and 2) multiple organ dysfunction or death in children with sepsis, severe sepsis, or septic shock. DATA SOURCES MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2004, and November 16, 2020. STUDY SELECTION Case-control studies, cohort studies, and randomized controlled trials in children greater than or equal to 37-week-old postconception to 18 years with suspected or confirmed infection, which included the terms "sepsis," "septicemia," or "septic shock" in the title or abstract. DATA EXTRACTION Study characteristics, patient demographics, clinical signs or interventions, laboratory values, organ dysfunction measures, and illness severity scores were extracted from eligible articles. Random-effects meta-analysis was performed. DATA SYNTHESIS One hundred and six studies met eligibility criteria of which 81 were included in the meta-analysis. Sixteen studies (9,629 patients) provided data for the sepsis, severe sepsis, or septic shock outcome and 71 studies (154,674 patients) for the mortality outcome. In children with infection, decreased level of consciousness and higher Pediatric Risk of Mortality scores were associated with sepsis/severe sepsis. In children with sepsis/severe sepsis/septic shock, chronic conditions, oncologic diagnosis, use of vasoactive/inotropic agents, mechanical ventilation, serum lactate, platelet count, fibrinogen, procalcitonin, multi-organ dysfunction syndrome, Pediatric Logistic Organ Dysfunction score, Pediatric Index of Mortality-3, and Pediatric Risk of Mortality score each demonstrated significant and consistent associations with mortality. Pooled mortality rates varied among high-, upper middle-, and lower middle-income countries for patients with sepsis, severe sepsis, and septic shock (p < 0.0001). CONCLUSIONS Strong associations of several markers of organ dysfunction with the outcomes of interest among infected and septic children support their inclusion in the data validation phase of the Pediatric Sepsis Definition Taskforce.
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Affiliation(s)
- Kusum Menon
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Luregn J. Schlapbach
- Pediatric and Neonatal ICU, University Children`s Hospital Zurich, Zurich, Switzerland, and Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Samuel Akech
- KEMRI Wellcome Trust Research Program, Nairobi, Kenya
| | - Andrew Argent
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, Cape Town, South Africa
| | - Paolo Biban
- Department of Paediatrics, Verona University Hospital, Verona, Italy
| | - Enitan D. Carrol
- Department of Clinical Infection Microbiology and Immunology, University of Liverpool Institute of Infection, Veterinary and Ecological Sciences, Liverpool, United Kingdom
| | | | | | - Idris V. R. Evans
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, and The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA
| | - David P. Inwald
- Paediatric Intensive Care Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Paul Ishimine
- Departments of Emergency Medicine and Pediatrics, University of California San Diego School of Medicine, La Jolla, CA
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia and British Columbia Children’s Hospital, Vancouver, BC, Canada
| | - Rakesh Lodha
- All India Institute of Medical Sciences, Delhi, India
| | - Simon Nadel
- St. Mary’s Hospital, Imperial College Healthcare NHS Trust, and Imperial College London, London, United Kingdom
| | | | - Mark Peters
- University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Benham Sadeghirad
- Departments of Anesthesia and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Halden F. Scott
- Departments of Pediatrics and Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Daniela C. de Souza
- Departments of Pediatrics, Hospital Sírio-Libanês and Hospital Universitário da Universidade de São Paulo, São Paolo, Brazil
| | - Pierre Tissieres
- Pediatric Intensive Care, AP-HP Paris Saclay University, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - R. Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Matthew O. Wiens
- University of British Columbia, Vancouver, BC, Canada
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - James L. Wynn
- Department of Pediatrics, University of Florida, Gainesville, FL
| | - Jerry J. Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Lauren R. Sorce
- Ann & Robert H. Lurie Children’s Hospital and Department of Pediatrics, Northwestern University Feinberg School of Medicine, Lurie Children’s Pediatric Research & Evidence Synthesis Center (PRECIISE): A JBI Affiliated Group, Chicago, IL
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Woods JM, Scott HF, Mullan PC, Badolato G, Sestokas J, Sarnacki R, Wolff M, Lane R, Dawson E, Kaplan R, Zaveri P. Using an eLearning Module to Facilitate Sepsis Knowledge Acquisition Across Multiple Institutions and Learner Disciplines. Pediatr Emerg Care 2021; 37:e1070-e1074. [PMID: 31464879 DOI: 10.1097/pec.0000000000001902] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Guidelines exist for care of pediatric sepsis, but no study has assessed the benefit of electronic learning (eLearning) in this topic area. The objective of this multicenter study was to assess knowledge acquisition and retention for pediatric sepsis across multiple health care provider roles, using an adaptive and interactive eLearning module. METHODS The study used pretest, posttest, and 90-day delayed test scores to evaluate provider knowledge after an adaptive and interactive eLearning module intervention. The eLearning module contained conditional logic-based assessments that allowed real-time adjustments of the displayed content according to each participant's demonstrated knowledge. Physicians, nurses, and advanced practice providers, primarily emergency department based, at 9 pediatric institutions were included. Changes in test scores were stratified by provider role. RESULTS A total of 574 participants completed the posttest, and 296 (51.6%) of those completed the delayed test. Across all providers, there was an increase in test scores of 15.7% between the pretest and posttest (P < 0.001) with a large effect size as measured by Cramer's V. Across all providers, there was an overall test score increase of 5.2% (P < 0.001) between the pretest and delayed test, with a small effect size. CONCLUSIONS An eLearning module improved immediate and delayed pediatric sepsis knowledge in pediatric health care providers across multiple institutions and provider roles. Immediate knowledge gain was meaningful as indicated by effect sizes, although by the time of the delayed test, the effect was smaller. This module fills an important gap in currently available pediatric sepsis education.
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Affiliation(s)
| | | | - Paul C Mullan
- Children's Hospital of the King's Daughters, Norfolk, VA
| | - Gia Badolato
- From the Children's National Health System, Washington, DC
| | - Jeff Sestokas
- From the Children's National Health System, Washington, DC
| | | | | | - Roni Lane
- Primary Children's Hospital, Salt Lake City, UT
| | | | - Ron Kaplan
- Seattle Children's Hospital, Seattle, WA
| | - Pavan Zaveri
- From the Children's National Health System, Washington, DC
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Abstract
OBJECTIVES Bundled pediatric sepsis care has been associated with improved outcomes in tertiary pediatric emergency departments. Sepsis care at nontertiary sites where most children seek emergency care is not well described. We sought to describe the rate of guideline-concordant care, and we hypothesized that guideline-concordant care in community pediatric emergency care settings would be associated with decreased hospital length of stay (LOS). METHOD This retrospective cohort study of children with severe sepsis presenting to pediatric community emergency and urgent care sites included children 60 days to 17 years with severe sepsis. The primary predictor was concordance with the American College of Critical Care Medicine 2017 pediatric sepsis resuscitation bundle, including timely recognition, vascular access, intravenous fluids, antibiotics, vasoactive agents as needed. RESULTS From January 1, 2015, to December 31, 2017, 90 patients with severe sepsis met inclusion criteria; 22 (24%) received guideline-concordant care. Children receiving concordant care had a median hospital LOS of 95.3 hours (50.9-163.8 hours), with nonconcordant care, LOS was 88.3 hours (57.3-193.2 hours). In adjusted analysis, guideline-concordant care was not associated with hospital LOS (incident rate ratio, 0.99 [0.64-1.52]). The elements that drove overall concordance were timely recognition, achieved in only half of cases, vascular access, and timely antibiotics. CONCLUSIONS Emergency care for pediatric sepsis in the community settings studied was concordant with guidelines in only 24% of the cases. Future study is needed to evaluate additional drivers of outcomes and ways to improve sepsis care in community emergency care settings.
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Affiliation(s)
- Emily Greenwald
- Department of Pediatrics, University of Colorado
- Section of Emergency Medicine, Department of Pediatrics, Children’s Hospital Colorado, Aurora, CO
| | | | - Jan Leonard
- Department of Pediatrics, University of Colorado
- Section of Emergency Medicine, Department of Pediatrics, Children’s Hospital Colorado, Aurora, CO
| | - Sara J. Deakyne Davies
- Research Informatics & Advanced Analytics, Analytics Resource Center, Children’s Hospital Colorado, Aurora, CO
| | - Julia Brant
- Department of Pediatrics, University of Colorado
- Section of Emergency Medicine, Department of Pediatrics, Children’s Hospital Colorado, Aurora, CO
| | - Halden F. Scott
- Department of Pediatrics, University of Colorado
- Section of Emergency Medicine, Department of Pediatrics, Children’s Hospital Colorado, Aurora, CO
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Stenson EK, You Z, Reeder R, Norris J, Scott HF, Dixon BP, Thurman JM, Frazer-Abel A, Mourani P, Kendrick J. Complement Activation Fragments Are Increased in Critically Ill Pediatric Patients with Severe AKI. Kidney360 2021; 2:1884-1891. [PMID: 35419539 PMCID: PMC8986038 DOI: 10.34067/kid.0004542021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/06/2021] [Indexed: 02/04/2023]
Abstract
Background Children who are critically ill with AKI suffer from high morbidity and mortality rates, and lack treatment options. Emerging evidence implicates the role of complement activation in AKI pathogenesis, which could potentially be treated with complement inhibitors. The purpose of this study is to evaluate the association between complement activation fragments and severity of AKI in children who are critically ill. Methods A biorepository of samples from children who are critically ill from a prior multisite study was leveraged to identify children with stage 3 AKI and matched to patients without AKI on the basis of PELOD-2 (illness severity) scores. Specimens were analyzed for plasma and urine complement activation fragments of factor B, C3a, C4a, and sC5b-9. The primary outcomes were MAKE30 and severe AKI rates. Results In total, 14 patients with stage 3 AKI (five requiring RRT) were matched to 14 patients without AKI. Urine factor Ba and plasma C4a levels increased stepwise as severity of AKI increased, from no AKI to stage 3 AKI, to stage 3 AKI with RRT need. Plasma C4a levels were independently associated with increased risk of MAKE30 outcomes (OR, 3.2; IQR, 1.1-8.9), and urine Ba (OR, 1.9; IQR, 1.1-3.1), plasma Bb (OR, 2.7; IQR, 1.1-6.8), C4a (OR, 13.0; IQR, 1.6-106.6), and C3a (OR, 3.3; IQR, 1.3-8.4) were independently associated with risk of severe stage 2-3 AKI on day 3 of admission. Conclusions Multiple complement fragments increase as magnitude of AKI severity increases. Very high levels of urine Ba or plasma C4a may identify patients at risk for severe AKI, hemodialysis, and MAKE30 outcomes. The fragments may be useful as a functional biomarker of complement activation and may identify those patients to study complement inhibition to treat or prevent AKI in children who are critically ill. These findings suggest the need for further specific investigations of the role of complement activation in children who are critically ill and at risk of AKI.
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Affiliation(s)
- Erin K. Stenson
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado,Department of Pediatrics, Section of Pediatric Critical Care, University of Colorado School of Medicine, Aurora, Colorado
| | - Zhiying You
- Division of Renal Disease and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ron Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Jesse Norris
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Halden F. Scott
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado,Department of Pediatrics, Section of Pediatric Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Bradley P. Dixon
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado,Department of Pediatrics, Section of Pediatric Nephrology, University of Colorado School of Medicine, Aurora, Colorado
| | - Joshua M. Thurman
- Division of Renal Disease and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ashley Frazer-Abel
- Department of Pediatrics, Exsera BioLabs, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Peter Mourani
- Division of Critical Care Medicine, Arkansas Children’s Hospital, Little Rock, Arkansas
| | - Jessica Kendrick
- Division of Renal Disease and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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15
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Lockwood JM, Scott HF, Wathen B, Rolison E, Smith C, Bundy J, Swanson A, Nickels S, Bakel LA, Bajaj L. An Acute Care Sepsis Response System Targeting Improved Antibiotic Administration. Hosp Pediatr 2021; 11:944-955. [PMID: 34404744 DOI: 10.1542/hpeds.2021-006011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Pediatric sepsis quality improvement in emergency departments has been well described and associated with improved survival. Acute care (non-ICU inpatient) units differ in important ways, and optimal approaches to improving sepsis processes and outcomes in this setting are not yet known. Our objective was to increase the proportion of acute care sepsis cases in our health system with initial antibiotic order-to-administration time ≤60 minutes by 20% from a baseline of 43% to 52% by December 2020. METHODS Employing the Model for Improvement with broad stakeholder engagement, we developed and implemented interventions aimed at effective intervention for sepsis cases on acute care units. We analyzed process and outcome metrics over time using statistical process control charts. We used descriptive statistics to explore differences in antibiotic order-to-administration time and inform ongoing improvement. RESULTS We cared for 187 patients with sepsis over the course of our initiative. The proportion within our goal antibiotic order-to-administration time rose from 43% to 64% with evidence of special cause variation after our interventions. Of all patients, 66% experienced ICU transfer and 4% died. CONCLUSIONS We successfully decreased antibiotic order-to-administration time. We also introduced a novel model for sepsis response systems that integrates interventions designed for the complexities of acute care settings. We demonstrated impactful local improvements in the acute care setting where quality improvement reports and success have previously been limited.
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Affiliation(s)
| | - Halden F Scott
- Emergency Medicine, Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | | | - Elise Rolison
- Clinical Effectiveness Team, Children's Hospital Colorado, Aurora, Colorado
| | - Carter Smith
- Clinical Effectiveness Team, Children's Hospital Colorado, Aurora, Colorado
| | - Jane Bundy
- Clinical Effectiveness Team, Children's Hospital Colorado, Aurora, Colorado
| | - Angela Swanson
- Clinical Effectiveness Team, Children's Hospital Colorado, Aurora, Colorado
| | - Sarah Nickels
- Clinical Effectiveness Team, Children's Hospital Colorado, Aurora, Colorado
| | - Leigh Anne Bakel
- Sections of Hospital Medicine.,Clinical Effectiveness Team, Children's Hospital Colorado, Aurora, Colorado
| | - Lalit Bajaj
- Emergency Medicine, Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado.,Clinical Effectiveness Team, Children's Hospital Colorado, Aurora, Colorado
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Abstract
OBJECTIVE The aim of this study was to identify emergency department (ED) heart rate (HR) values that identify children at elevated risk of ED revisit with admission. METHODS We performed a retrospective cohort study of patients 0 to 18 years old discharged from a tertiary-care pediatric ED from January 2013 to December 2014. We created percentile curves for the last recorded HR for age using data from calendar year 2013 and used receiver operating characteristic (ROC) curves to characterize the performance of the percentiles for predicting ED revisit with admission within 72 hours. In a held-out validation data set (calendar year 2014 data), we evaluated test characteristics of last-recorded HR-for-age cut points identified as promising on the ROC curves, as well as those identifying the highest 5% and 1% of last recorded HRs for age. RESULTS We evaluated 183,433 eligible ED visits. Last recorded HR for age had poor discrimination for predicting revisit with admission (area under the curve, 0.61; 95% confidence interval, 0.58-0.63). No promising cut points were identified on the ROC curves. Cut points identifying the highest 5% and 1% of last recorded HRs for age showed low sensitivity (10.1% and 2.5%) with numbers needed to evaluate of 62 and 50, respectively, to potentially prevent 1 revisit with admission. CONCLUSIONS Last recorded ED HR discriminates poorly between children who are and are not at risk of revisit with admission in a pediatric ED. The use of single-parameter HR in isolation as an automated trigger for mandatory reevaluation prior to discharge may not improve revisit outcomes.
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Affiliation(s)
- Carrie Daymont
- Departments of Pediatrics and Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Fran Balamuth
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Halden F Scott
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Christopher P Bonafide
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Patrick W Brady
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Holly Depinet
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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17
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Larsen GY, Brilli R, Macias CG, Niedner M, Auletta JJ, Balamuth F, Campbell D, Depinet H, Frizzola M, Hueschen L, Lowerre T, Mack E, Paul R, Razzaqi F, Schafer M, Scott HF, Silver P, Wathen B, Lukasiewicz G, Stuart J, Riggs R, Richardson T, Ward L, Huskins WC. Development of a Quality Improvement Learning Collaborative to Improve Pediatric Sepsis Outcomes. Pediatrics 2021; 147:e20201434. [PMID: 33328337 PMCID: PMC7874527 DOI: 10.1542/peds.2020-1434] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2020] [Indexed: 12/29/2022] Open
Abstract
Pediatric sepsis is a major public health problem. Published treatment guidelines and several initiatives have increased adherence with guideline recommendations and have improved patient outcomes, but the gains are modest, and persistent gaps remain. The Children's Hospital Association Improving Pediatric Sepsis Outcomes (IPSO) collaborative seeks to improve sepsis outcomes in pediatric emergency departments, ICUs, general care units, and hematology/oncology units. We developed a multicenter quality improvement learning collaborative of US children's hospitals. We reviewed treatment guidelines and literature through 2 in-person meetings and multiple conference calls. We defined and analyzed baseline sepsis-attributable mortality and hospital-onset sepsis and developed a key driver diagram (KDD) on the basis of treatment guidelines, available evidence, and expert opinion. Fifty-six hospital-based teams are participating in IPSO; 100% of teams are engaged in educational and information-sharing activities. A baseline, sepsis-attributable mortality of 3.1% was determined, and the incidence of hospital-onset sepsis was 1.3 cases per 1000 hospital admissions. A KDD was developed with the aim of reducing both the sepsis-attributable mortality and the incidence of hospital-onset sepsis in children by 25% from baseline by December 2020. To accomplish these aims, the KDD primary drivers focus on improving the following: treatment of infection; recognition, diagnosis, and treatment of sepsis; de-escalation of unnecessary care; engagement of patients and families; and methods to optimize performance. IPSO aims to improve sepsis outcomes through collaborative learning and reliable implementation of evidence-based interventions.
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Affiliation(s)
- Gitte Y Larsen
- Pediatric Critical Care, Primary Children's Hospital and Department of Pediatrics, University of Utah, Salt Lake City, Utah;
| | | | - Charles G Macias
- Pediatric Emergency Medicine, Rainbow Babies and Children's Hospital and Case Western Reserve University, Cleveland, Ohio
| | - Matthew Niedner
- Pediatric Critical Care, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Jeffery J Auletta
- Hematology, Oncology, and Blood and Marrow Transplant, and Infectious Diseases, Nationwide Children's Hospital, Columbus, Ohio
| | - Fran Balamuth
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Deborah Campbell
- Infection Prevention and Quality, Kentucky Hospital Association, Louisville, Kentucky
| | - Holly Depinet
- Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Meg Frizzola
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, Delaware
| | - Leslie Hueschen
- Pediatric Emergency Medicine, Children's Mercy Hospital and University of Missouri, Kansas City, Missouri
| | - Tracy Lowerre
- Acute Care Pediatric Unit, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Elizabeth Mack
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Raina Paul
- Pediatric Emergency Medicine, Advocate Children's Hospital, Park Ridge, Illinois
| | - Faisal Razzaqi
- Pediatric Hematology and Oncology, Valley Children's Hospital, Madera, California
| | - Melissa Schafer
- Department of Pediatrics, State University of New York Upstate Medical University and Upstate Golisano Children's Hospital, Syracuse, New York
| | - Halden F Scott
- Pediatric Emergency Medicine, Children's Hospital Colorado and Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Pete Silver
- Cohen Children's Medical Center of New York and Department of Pediatrics, Zucker School of Medicine at Hofstra/Northwell, Queens, New York
| | - Beth Wathen
- Pediatric ICU, Children's Hospital Colorado, Aurora, Colorado
| | - Gloria Lukasiewicz
- Children's Hospital Association, Lenexa, Kansas
- Children's Hospital Association, Washington, District of Columbia; and
| | - Jayne Stuart
- Children's Hospital Association, Lenexa, Kansas
- Children's Hospital Association, Washington, District of Columbia; and
| | - Ruth Riggs
- Children's Hospital Association, Lenexa, Kansas
- Children's Hospital Association, Washington, District of Columbia; and
| | - Troy Richardson
- Children's Hospital Association, Lenexa, Kansas
- Children's Hospital Association, Washington, District of Columbia; and
| | - Lowrie Ward
- Children's Hospital Association, Lenexa, Kansas
- Children's Hospital Association, Washington, District of Columbia; and
| | - W Charles Huskins
- Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
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18
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Scott HF, Colborn KL, Sevick CJ, Bajaj L, Deakyne Davies SJ, Fairclough D, Kissoon N, Kempe A. Development and Validation of a Model to Predict Pediatric Septic Shock Using Data Known 2 Hours After Hospital Arrival. Pediatr Crit Care Med 2021; 22:16-26. [PMID: 33060422 PMCID: PMC7790844 DOI: 10.1097/pcc.0000000000002589] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective: To use Electronic Health Record (EHR) data from the first two hours of care to derive and validate a model to predict hypotensive septic shock in children with infection. Design: Derivation-validation study using an existing registry Setting: Six emergency care sites within a regional pediatric healthcare system. Three datasets of unique visits were designated: Patients: Patients in whom clinicians were concerned about serious infection from 60 days-17 years were included; those with septic shock in the first two hours were excluded. There were 2318 included visits; 197 developed septic shock (8.5%). Interventions: Lasso with tenfold cross-validation was used for variable selection; logistic regression was then used to construct a model from those variables in the training set. Variables were derived from EHR data known in the first two hours, including vital signs, medical history, demographics, laboratory information. Test characteristics at two thresholds were evaluated: 1) optimizing sensitivity and specificity, 2) set to 90% sensitivity. Measurements and Main Results: Septic shock was defined as systolic hypotension and vasoactive use or ≥30 ml/kg isotonic crystalloid administration in the first 24 hours. A model was created using twenty predictors, with an area under the receiver operating curve in the training set of 0.85 (0.82-0.88); 0.83 [0.78-0.89] in the temporal test set; 0.83 [0.60-1.00] in the geographic test set. Sensitivity and specificity varied based on cutpoint; when sensitivity in the training set was set to 90% (83%, 94%), specificity was 62% (60%, 65%). Conclusions: This model predicted risk of septic shock in children with suspected infection 2 hours after arrival, a critical timepoint for emergent treatment and transfer decisions. Varied cutpoints could be used to customize sensitivity to clinical context.
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Affiliation(s)
- Halden F. Scott
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, CO, United States
| | - Kathryn L. Colborn
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Carter J. Sevick
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, United States and Children's Hospital Colorado, Aurora, CO, United States
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, CO, United States
- Center for Clinical Effectiveness, Children’s Hospital Colorado, Aurora CO, United States
| | | | - Diane Fairclough
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, United States and Children's Hospital Colorado, Aurora, CO, United States
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Niranjan Kissoon
- British Columbia Children’s Hospital, Vancouver, BC, Canada
- University of British Columbia, Vancouver, BC, Canada
| | - Allison Kempe
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, United States and Children's Hospital Colorado, Aurora, CO, United States
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19
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Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, Nadel S, Schlapbach LJ, Tasker RC, Argent AC, Brierley J, Carcillo J, Carrol ED, Carroll CL, Cheifetz IM, Choong K, Cies JJ, Cruz AT, De Luca D, Deep A, Faust SN, De Oliveira CF, Hall MW, Ishimine P, Javouhey E, Joosten KFM, Joshi P, Karam O, Kneyber MCJ, Lemson J, MacLaren G, Mehta NM, Møller MH, Newth CJL, Nguyen TC, Nishisaki A, Nunnally ME, Parker MM, Paul RM, Randolph AG, Ranjit S, Romer LH, Scott HF, Tume LN, Verger JT, Williams EA, Wolf J, Wong HR, Zimmerman JJ, Kissoon N, Tissieres P. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med 2020; 46:10-67. [PMID: 32030529 PMCID: PMC7095013 DOI: 10.1007/s00134-019-05878-6] [Citation(s) in RCA: 266] [Impact Index Per Article: 66.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objectives To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction. Design A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. Methods The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, “in our practice” statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. Results The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 49 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, “in our practice” statements were provided. In addition, 52 research priorities were identified. Conclusions A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.
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Affiliation(s)
- Scott L Weiss
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Mark J Peters
- Great Ormond Street Hospital for Children, London, UK
| | - Waleed Alhazzani
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael S D Agus
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Luregn J Schlapbach
- Paediatric Critical Care Research Group, The University of Queensland and Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Robert C Tasker
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew C Argent
- Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Joe Brierley
- Great Ormond Street Hospital for Children, London, UK
| | | | | | | | | | - Karen Choong
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeffry J Cies
- St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | | | - Daniele De Luca
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Physiopathology and Therapeutic Innovation Unit-INSERM U999, South Paris-Saclay University, Paris, France
| | | | - Saul N Faust
- University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | | | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH, USA
| | | | | | | | - Poonam Joshi
- All India Institute of Medical Sciences, New Delhi, India
| | - Oliver Karam
- Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | | | - Joris Lemson
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Graeme MacLaren
- National University Health System, Singapore, Singapore.,Royal Children's Hospital, Melbourne, VIC, Australia
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Akira Nishisaki
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mark E Nunnally
- New York University Langone Medical Center, New York, NY, USA
| | | | - Raina M Paul
- Advocate Children's Hospital, Park Ridge, IL, USA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | | | - Judy T Verger
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,College of Nursing, University of Iowa, Iowa City, IA, USA
| | | | - Joshua Wolf
- St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | | | - Pierre Tissieres
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Institute of Integrative Biology of the Cell-CNRS, CEA, Univ Paris Sud, Gif-Sur-Yvette, France
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20
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Affiliation(s)
- Fran Balamuth
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; .,Division of Emergency Medicine and Pediatric Sepsis Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elizabeth R. Alpern
- Department of Pediatrics, Feinberg School of Medicine,
Northwestern University and Ann and Robert H. Lurie Children’s Hospital of
Chicago, Chicago, Illinois
| | - Halden F. Scott
- Department of Pediatrics, School of Medicine, University of
Colorado, Aurora, Colorado,Division of Emergency Medicine, Children’s Hospital
Colorado, Aurora, Colorado
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21
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Scott HF, Balamuth F, Alpern ER. The Legacy of Pediatric Sepsis State Legislation. Pediatrics 2020; 146:peds.2020-1525. [PMID: 32605993 PMCID: PMC7417071 DOI: 10.1542/peds.2020-1525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Halden F. Scott
- Department of Pediatrics and Emergency Medicine, School of Medicine, University of Colorado, Aurora, Colorado,Department of Children’s Hospital Colorado, Aurora, Colorado
| | - Fran Balamuth
- Department of Division of Pediatric Emergency Medicine, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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22
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Scott HF, Colborn KL, Sevick CJ, Bajaj L, Kissoon N, Deakyne Davies SJ, Kempe A. Development and Validation of a Predictive Model of the Risk of Pediatric Septic Shock Using Data Known at the Time of Hospital Arrival. J Pediatr 2020; 217:145-151.e6. [PMID: 31733815 PMCID: PMC6980682 DOI: 10.1016/j.jpeds.2019.09.079] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/25/2019] [Accepted: 09/27/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To derive and validate a model of risk of septic shock among children with suspected sepsis, using data known in the electronic health record at hospital arrival. STUDY DESIGN This observational cohort study at 6 pediatric emergency department and urgent care sites used a training dataset (5 sites, April 1, 2013, to December 31, 2016), a temporal test set (5 sites, January 1, 2017 to June 30, 2018), and a geographic test set (a sixth site, April 1, 2013, to December 31, 2018). Patients 60 days to 18 years of age in whom clinicians suspected sepsis were included; patients with septic shock on arrival were excluded. The outcome, septic shock, was systolic hypotension with vasoactive medication or ≥30 mL/kg of isotonic crystalloid within 24 hours of arrival. Elastic net regularization, a penalized regression technique, was used to develop a model in the training set. RESULTS Of 2464 included visits, septic shock occurred in 282 (11.4%). The model had an area under the curve of 0.79 (0.76-0.83) in the training set, 0.75 (0.69-0.81) in the temporal test set, and 0.87 (0.73-1.00) in the geographic test set. With a threshold set to 90% sensitivity in the training set, the model yielded 82% (72%-90%) sensitivity and 48% (44%-52%) specificity in the temporal test set, and 90% (55%-100%) sensitivity and 32% (21%-46%) specificity in the geographic test set. CONCLUSIONS This model estimated the risk of septic shock in children at hospital arrival earlier than existing models. It leveraged the predictive value of routine electronic health record data through a modern predictive algorithm and has the potential to enhance clinical risk stratification in the critical moments before deterioration.
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Affiliation(s)
- Halden F Scott
- Department of Pediatrics, University of Colorado, Aurora, CO; Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, CO.
| | - Kathryn L Colborn
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Carter J Sevick
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado, Aurora, CO; Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, CO; Center for Clinical Effectiveness, Children's Hospital Colorado, Aurora, CO
| | - Niranjan Kissoon
- Division of Critical Care, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; Department of Pediatrics and Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Allison Kempe
- Department of Pediatrics, University of Colorado, Aurora, CO; Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO
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23
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Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, Nadel S, Schlapbach LJ, Tasker RC, Argent AC, Brierley J, Carcillo J, Carrol ED, Carroll CL, Cheifetz IM, Choong K, Cies JJ, Cruz AT, De Luca D, Deep A, Faust SN, De Oliveira CF, Hall MW, Ishimine P, Javouhey E, Joosten KFM, Joshi P, Karam O, Kneyber MCJ, Lemson J, MacLaren G, Mehta NM, Møller MH, Newth CJL, Nguyen TC, Nishisaki A, Nunnally ME, Parker MM, Paul RM, Randolph AG, Ranjit S, Romer LH, Scott HF, Tume LN, Verger JT, Williams EA, Wolf J, Wong HR, Zimmerman JJ, Kissoon N, Tissieres P. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med 2020; 21:e52-e106. [PMID: 32032273 DOI: 10.1097/pcc.0000000000002198] [Citation(s) in RCA: 458] [Impact Index Per Article: 114.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction. DESIGN A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. METHODS The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. RESULTS The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 52 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 49 research priorities were identified. CONCLUSIONS A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.
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Affiliation(s)
- Scott L Weiss
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Mark J Peters
- Great Ormond Street Hospital for Children, London, United Kingdom
| | - Waleed Alhazzani
- Department of Medicine, Division of Critical Care, and Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael S D Agus
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Luregn J Schlapbach
- Paediatric Critical Care Research Group, The University of Queensland and Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Robert C Tasker
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Andrew C Argent
- Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Joe Brierley
- Great Ormond Street Hospital for Children, London, United Kingdom
| | | | | | | | | | - Karen Choong
- Department of Medicine, Division of Critical Care, and Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeffry J Cies
- St. Christopher's Hospital for Children, Philadelphia, PA
| | | | - Daniele De Luca
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Physiopathology and Therapeutic Innovation Unit-INSERM U999, South Paris-Saclay University, Paris, France
| | - Akash Deep
- King's College Hospital, London, United Kingdom
| | - Saul N Faust
- University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | | | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH
| | | | | | | | - Poonam Joshi
- All India Institute of Medical Sciences, New Delhi, India
| | - Oliver Karam
- Children's Hospital of Richmond at VCU, Richmond, VA
| | | | - Joris Lemson
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Graeme MacLaren
- National University Health System, Singapore, and Royal Children's Hospital, Melbourne, VIC, Australia
| | - Nilesh M Mehta
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Akira Nishisaki
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | | | | | - Adrienne G Randolph
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Lyvonne N Tume
- University of the West of England, Bristol, United Kingdom
| | - Judy T Verger
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,College of Nursing, University of Iowa, Iowa City, IA
| | | | - Joshua Wolf
- St. Jude Children's Research Hospital, Memphis, TN
| | | | | | - Niranjan Kissoon
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Pierre Tissieres
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Institute of Integrative Biology of the Cell-CNRS, CEA, Univ Paris Sud, Gif-sur-Yvette, France
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24
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Affiliation(s)
| | - Fran Balamuth
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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25
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Woods JM, Scott HF, Zaveri PP. Creating Consensus Educational Goals for Pediatric Sepsis via Multicenter Modified Delphi. AEM Educ Train 2018; 2:254-258. [PMID: 30386834 PMCID: PMC6194036 DOI: 10.1002/aet2.10123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/28/2018] [Accepted: 07/30/2018] [Indexed: 06/08/2023]
Abstract
Clinical care of pediatric sepsis depends on early recognition and basic initial steps and thus focused educational materials for providers in these early phases of care are needed. The authors sought to identify educational goals and establish a framework for those materials. The authors conducted a Delphi process to create consensus educational goals for the recognition and treatment of pediatric sepsis, focused on the needs of emergency and acute care providers. Experts in pediatric sepsis quality improvement and education were recruited. In each round the experts determined if a particular goal was appropriate for inclusion and provided edits if required. Free-text responses and additional goals were accepted. The primary author deidentified and collated the responses and distributed an updated list of goals prior to each round. Five experts participated in the Delphi process. After three rounds the panelists unanimously agreed on 14 educational goals. These goals include three on recognition, five on early treatment, three on treatment response, and three on continued treatment. Using a Delphi process the authors established a list of educational goals for pediatric sepsis care. The experts largely agreed upon the initial set of goals and quickly came to consensus on the majority of topics. This highlights a foundation for any future educational interventions. In addition to creating content standards for pediatric sepsis education, this Delphi process represents a useful tool that may be adaptable to educational content development in other topics.
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Affiliation(s)
- Jason M. Woods
- Children's National Medical CenterWashingtonDC
- Children's Hospital ColoradoAuroraCO
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Scott HF, Greenwald EE, Bajaj L, Deakyne Davies SJ, Brou L, Kempe A. The Sensitivity of Clinician Diagnosis of Sepsis in Tertiary and Community-Based Emergency Settings. J Pediatr 2018; 195:220-227.e1. [PMID: 29395173 DOI: 10.1016/j.jpeds.2017.11.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 10/02/2017] [Accepted: 11/15/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess whether the risk of missed clinician diagnosis of pediatric sepsis requiring care in the intensive care unit (ICU) was greater in community vs tertiary pediatric emergency care settings with sepsis pathways. STUDY DESIGN An observational cohort study in a tertiary pediatric emergency department (ED) staffed by pediatric emergency physicians and 4 affiliated community pediatric ED/urgent care sites staffed by general pediatricians. Use of an institutional sepsis order set or pathway was considered clinician diagnosis of sepsis. Risk of missed diagnosis was compared for 2 outcomes: suspected infection plus ICU admission (sepsis-ICU) and suspected infection plus vasoactive agent/positive-pressure ventilation (sepsis-VV). RESULTS From January 1, 2014 to December 31, 2015, there were 141 552 tertiary and 139 332 community emergency visits. Clinicians diagnosed sepsis in 1136 visits; median age was 5.7 (2.4, 12.0) years. In the tertiary ED, there were 306 sepsis-ICU visits (0.2%) and 112 sepsis-VV visits (0.08%). In community sites, there were 46 sepsis-ICU visits (0.03%) and 20 sepsis-VV visits (0.01%). The risk of missed diagnosis in community vs tertiary sites was significantly greater for sepsis-ICU (relative risk 4.30, CI 2.15-8.60) and sepsis-VV (relative risk 14.0, CI 2.91-67.24). Sensitivity for sepsis-ICU was 94.4% (91.3%-96.5%) at the tertiary site and 76.1% (62.1%-86.1%) at community sites. CONCLUSIONS The risk of missed diagnosis of sepsis-ICU was greater in community vs tertiary emergency care settings despite shared pathways and education, but with differences in resources, providers, and sepsis incidence. More research is needed to optimize diagnostic approaches in all settings.
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Affiliation(s)
- Halden F Scott
- Department of Pediatrics, University of Colorado, Aurora, CO; Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado, Aurora, CO.
| | - Emily E Greenwald
- Department of Pediatrics, University of Colorado, Aurora, CO; Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado, Aurora, CO; Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado, Aurora, CO; Center for Clinical Effectiveness, Children's Hospital Colorado, Aurora, CO; Research Informatics, Children's Hospital Colorado, Aurora, CO
| | | | - Lina Brou
- Department of Pediatrics, University of Colorado, Aurora, CO
| | - Allison Kempe
- Department of Pediatrics, University of Colorado, Aurora, CO; Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado, Aurora, CO
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Spruiell MD, Searns JB, Heare TC, Roberts JL, Wylie E, Pyle L, Donaldson N, Stewart JR, Heizer H, Reese J, Scott HF, Pearce K, Anderson CJ, Erickson M, Parker SK. Clinical Care Guideline for Improving Pediatric Acute Musculoskeletal Infection Outcomes. J Pediatric Infect Dis Soc 2017; 6:e86-e93. [PMID: 28419275 DOI: 10.1093/jpids/pix014] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 01/24/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Acute pediatric musculoskeletal infections are common, leading to significant use of resources and antimicrobial exposure. In order to decrease variability and improve the quality of care, Children's Hospital Colorado implemented a clinical care guideline (CCG) for these infections. The purpose of this study is to evaluate clinical and resource outcomes PRE and POST this CCG. METHODS Retrospective chart review evaluated patients admitted to a large pediatric quaternary referral center (CHCO) diagnosed with acute osteomyelitis, septic arthritis, pyomyositis, and/or musculoskeletal abscess prior to and after guideline implementation. Primary outcomes included length of stay and overall antibiotic use, with additional secondary clinical, process, and therapeutic outcomes examined. RESULTS 82 patients were identified in both the pre-CCG and post-CCG cohorts. There was a reduction in the median of all primary outcomes, including length of stay (0.6 median days decrease, P = .04), length of IV antibiotic therapy (4.9 median days decrease, P < .0001), and days of IV antibiotic therapy (6.4 median days decrease, P = .0004). Our median length of stay post-CCG was 4.9 days, the shortest reported length of stay for pediatric acute musculoskeletal infections to date. Additionally, there was a 24.5 hour reduction in median length of fever (P = .02), faster CRP normalization (P < .0001), 50% decrease in the number of related readmissions (P = .02), 34% decrease in central venous catheters placed (P < .0001), decreased time to first culture (P = .02), and 79% pathogen identification post-CCG (P = .056). CONCLUSIONS Implementation of a CCG for acute musculoskeletal infections improves patient, process and resource outcomes.
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Affiliation(s)
- Murray D Spruiell
- Department of Orthopedic Surgery, University of Colorado Denver School of Medicine, Aurora
| | | | - Travis C Heare
- Department of Orthopedic Surgery, University of Colorado Denver School of Medicine, Aurora
| | - Jesse L Roberts
- Department of Orthopedic Surgery, University of Colorado Denver School of Medicine, Aurora
| | - Erin Wylie
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Children's Hospital Colorado, Aurora
| | - Laura Pyle
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora.,Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora
| | - Nathan Donaldson
- Department of Orthopedic Surgery, University of Colorado Denver School of Medicine, Aurora
| | | | | | - Jennifer Reese
- Division of Pediatric Hospital Medicine, Department of Pediatrics
| | | | - Kelly Pearce
- Department of Epidemiology, Children's Hospital Colorado, Aurora
| | - Colin J Anderson
- Department of Orthopedic Surgery, University of Colorado Denver School of Medicine, Aurora
| | - Mark Erickson
- Department of Orthopedic Surgery, University of Colorado Denver School of Medicine, Aurora
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Affiliation(s)
- Halden F Scott
- Department of Pediatrics, University of Colorado School of Medicine, Aurora.,Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora
| | - Allison Kempe
- Department of Pediatrics, University of Colorado School of Medicine, Aurora.,Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado, Aurora
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado School of Medicine, Aurora.,Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora
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Scott HF, Brou L, Deakyne SJ, Kempe A, Fairclough DL, Bajaj L. Association Between Early Lactate Levels and 30-Day Mortality in Clinically Suspected Sepsis in Children. JAMA Pediatr 2017; 171:249-255. [PMID: 28068437 DOI: 10.1001/jamapediatrics.2016.3681] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Improving emergency care of pediatric sepsis is a public health priority, but optimal early diagnostic approaches are unclear. Measurement of lactate levels is associated with improved outcomes in adult septic shock, but pediatric guidelines do not endorse its use, in part because the association between early lactate levels and mortality is unknown in pediatric sepsis. OBJECTIVE To determine whether the initial serum lactate level is associated with 30-day mortality in children with suspected sepsis. DESIGN, SETTING, AND PARTICIPANTS This observational cohort study of a clinical registry of pediatric patients with suspected sepsis in the emergency department of a tertiary children's hospital from April 1, 2012, to December 31, 2015, tested the hypothesis that a serum lactate level of greater than 36 mg/dL is associated with increased mortality compared with a serum lactate level of 36 mg/dL or less. Consecutive patients with sepsis were identified and included in the registry following consensus guidelines for clinical recognition (infection and decreased mental status or perfusion). Among 2520 registry visits, 1221 were excluded for transfer from another medical center, no measurement of lactate levels, and patients younger than 61 days or 18 years or older, leaving 1299 visits available for analysis. Lactate testing is prepopulated in the institutional sepsis order set but may be canceled at clinical discretion. EXPOSURES Venous lactate level of greater than 36 mg/dL on the first measurement within the first 8 hours after arrival. MAIN OUTCOMES AND MEASURES Thirty-day in-hospital mortality was the primary outcome. Odds ratios were calculated using logistic regression to account for potential confounders. RESULTS Of the 1299 patients included in the analysis (753 boys [58.0%] and 546 girls [42.0%]; mean [SD] age, 7.3 [5.3] years), 899 (69.2%) had chronic medical conditions and 367 (28.3%) had acute organ dysfunction. Thirty-day mortality occurred in 5 of 103 patients (4.8%) with lactate levels greater than 36 mg/dL and 20 of 1196 patients (1.7%) with lactate levels of 36 mg/dL or less. Initial lactate levels of greater than 36 mg/dL were significantly associated with 30-day mortality in unadjusted (odds ratio, 3.00; 95% CI, 1.10-8.17) and adjusted (odds ratio, 3.26; 95% CI, 1.16- 9.16) analyses. The sensitivity of lactate levels greater than 36 mg/dL for 30-day mortality was 20.0% (95% CI, 8.9%-39.1%), and specificity was 92.3% (90.7%-93.7%). CONCLUSIONS AND RELEVANCE In children treated for sepsis in the emergency department, lactate levels greater than 36 mg/dL were associated with mortality but had a low sensitivity. Measurement of lactate levels may have utility in early risk stratification of pediatric sepsis.
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Affiliation(s)
- Halden F Scott
- Department of Pediatrics, University of Colorado, Aurora2Section of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora
| | - Lina Brou
- Department of Pediatrics, University of Colorado, Aurora
| | - Sara J Deakyne
- Department of Pediatrics, Children's Hospital Colorado, Aurora
| | - Allison Kempe
- Department of Pediatrics, University of Colorado, Aurora3Department of Pediatrics, Children's Hospital Colorado, Aurora4Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado, Aurora
| | - Diane L Fairclough
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado, Aurora5Colorado School of Public Health, Aurora
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado, Aurora2Section of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora
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de Caen AR, Berg MD, Chameides L, Gooden CK, Hickey RW, Scott HF, Sutton RM, Tijssen JA, Topjian A, van der Jagt ÉW, Schexnayder SM, Samson RA. Part 12: Pediatric Advanced Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S526-42. [PMID: 26473000 PMCID: PMC6191296 DOI: 10.1161/cir.0000000000000266] [Citation(s) in RCA: 345] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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de Caen AR, Berg MD, Chameides L, Gooden CK, Hickey RW, Scott HF, Sutton RM, Tijssen JA, Topjian A, van der Jagt ÉW, Schexnayder SM, Samson RA. Part 12: Pediatric Advanced Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (Reprint). Pediatrics 2015; 136 Suppl 2:S176-95. [PMID: 26471384 DOI: 10.1542/peds.2015-3373f] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Chiotos K, Balamuth F, Scott HF. Management of bacterial severe sepsis and septic shock. J Pediatr Intensive Care 2015; 3:227-242. [PMID: 31214470 DOI: 10.3233/pic-14105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 10/07/2014] [Indexed: 11/15/2022] Open
Abstract
Bacterial sepsis is a leading cause of pediatric morbidity and mortality worldwide. Early diagnosis, a coordinated and aggressive approach to initial resuscitation, and timely and appropriate antibiotic therapy are paramount to improving outcomes of these dangerous infections. The basic tenants of initial and ongoing resuscitation include rapid isotonic intravenous fluid boluses with reassessment for physiologic response, empiric broad-spectrum antibiotics directed to cover suspected sources of infection, source control, vasoactive infusions, supportive critical care and monitoring of response to therapy. In addition to resuscitation of bacterial sepsis, this article will review approaches to empiric antibiotic choice in septic shock, and detail definitive management of infections caused by several specific organisms, including Staphylococcus aureus , group A Streptococcus, Pseudomonas aeruginosa, Mycobacterium tuberculosis , and Clostridium difficile . Lastly, management of several common pediatric infections, including community acquired bacterial pneumonia and bacterial meningitis, will be reviewed.
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Affiliation(s)
- Kathleen Chiotos
- Division of Critical Care, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Fran Balamuth
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Emergency Medicine and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Halden F Scott
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.,Section of Emergency Medicine, Children's Hospital Colorado, Aurora, CO, USA
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Scott HF, Deakyne SJ, Woods JM, Bajaj L. The prevalence and diagnostic utility of systemic inflammatory response syndrome vital signs in a pediatric emergency department. Acad Emerg Med 2015; 22:381-9. [PMID: 25778743 DOI: 10.1111/acem.12610] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 09/30/2014] [Accepted: 10/15/2014] [Indexed: 12/22/2022]
Abstract
OBJECTIVES This study sought to determine the prevalence, test characteristics, and severity of illness of pediatric patients with systemic inflammatory response syndrome (SIRS) vital signs among pediatric emergency department (ED) visits. METHODS This was a retrospective descriptive cohort study of all visits to the ED of a tertiary academic free-standing pediatric hospital over 1 year. Visits were included if the patient was <18 years of age and did not leave before full evaluation or against medical advice. Exclusion criteria were trauma diagnoses or missing documentation of vital signs. Data were electronically extracted from the medical record. The primary predictor was presence of vital signs meeting pediatric SIRS definitions. Specific vital sign pairs comprising SIRS were evaluated as predictors (temperature-heart rate, temperature-respiratory rate, and temperature-corrected heart rate, in which a formula was used to correct heart rate for degree of temperature elevation). The primary outcome measure was requirement for critical care (receipt of a vasoactive agent or intubation) within 24 hours of ED arrival. RESULTS There were 56,210 visits during the study period; 40,356 met inclusion criteria. Of these, 6,596 (16.3%) visits had fever >38.5°C, and 6,122 (15.2% of included visits) met SIRS vital sign criteria. Among included visits, those with SIRS vital signs accounted for 92.8% of all visits with fever >38.5°C. Among patients with SIRS vital signs, 4993 (81.6%) were discharged from the ED without intravenous (IV) therapy and without 72-hour readmission. Critical care within the first 24 hours was present in 99 (0.25%) patients: 23 patients with and 76 without SIRS vital signs. Intensive care unit (ICU) admission was present in 126 (2.06%) with SIRS vital signs and 487 (1.42%) without SIRS vital signs. SIRS vital signs were associated with increased risk of critical care within 24 hours (relative risk [RR] = 1.69, 95% confidence interval [CI] = 1.06 to 2.70), ICU admission (RR = 1.45, 95% CI = 1.19 to 1.76), ED laboratory tests (RR = 1.41, 95% CI = 1.37 to 1.45), ED IV medication/fluid administration (RR = 2.54, 95% CI = 2.29 to 2.82), hospital admission (RR = 1.52, 95% CI = 1.42 to 1.63), and 72-hour readmission (RR = 1.31, 95% CI = 1.01 to 1.69). SIRS vital signs were not associated with 30-day in-hospital mortality (RR = 0.37, 95% CI = 0.05 to 2.82). SIRS vital signs had a low sensitivity for critical care requirement (23.2%, 95% CI = 15.3% to 32.8%). The pair of SIRS vital signs with the strongest association with critical care requirement was temperature and corrected heart rate (positive likelihood ratio = 2.74, 95% CI = 1.87 to 4.01). CONCLUSIONS Systemic inflammatory response syndrome vital signs are common among medical pediatric patients presenting to an ED, and critical illness is rare. The majority of patients with SIRS vital signs were discharged without IV therapy and without readmission. Patients with SIRS vital signs had a statistically significant increased risk of critical care requirement, ED IV treatment, ED laboratory tests, admission, and readmission. However, SIRS vital sign criteria did not identify the majority of patients with mortality or need for critical care. SIRS vital signs had low sensitivity for critical illness, making it poorly suited for use in isolation in this setting as a test to detect children requiring sepsis resuscitation.
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Affiliation(s)
- Halden F. Scott
- Department of Pediatrics; Section of Emergency Medicine; Children's Hospital Colorado; University of Colorado School of Medicine; Aurora CO
| | - Sara J. Deakyne
- Research Informatics; Research Institute; Children's Hospital Colorado; Aurora CO
| | - Jason M. Woods
- Children's National Health System; The George Washington University School of Medicine; Washington DC
| | - Lalit Bajaj
- Department of Pediatrics; Section of Emergency Medicine; Children's Hospital Colorado; University of Colorado School of Medicine; Aurora CO
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Scott HF, Donoghue AJ, Gaieski DF, Marchese RF, Mistry RD. Effectiveness of physical exam signs for early detection of critical illness in pediatric systemic inflammatory response syndrome. BMC Emerg Med 2014; 14:24. [PMID: 25407007 PMCID: PMC4289256 DOI: 10.1186/1471-227x-14-24] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 10/30/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Early detection of compensated pediatric septic shock requires diagnostic tests that are sensitive and specific. Four physical exam signs are recommended for detecting pediatric septic shock prior to hypotension (cold extremities, mental status, capillary refill, peripheral pulse quality); this study tested their ability to detect patients who develop organ dysfunction among a cohort of undifferentiated pediatric systemic inflammatory response syndrome patients. METHODS A prospective cohort of 239 pediatric emergency department patients <19 years with fever and tachycardia and undergoing phlebotomy were enrolled. Physicians recorded initial physical exams on a standardized form. Abstraction of the medical record determined outcomes including organ dysfunction, intensive care unit stay, serious bacterial infection, and therapies. RESULTS Organ dysfunction occurred in 13/239 (5.4%) patients. Presence of at least one sign was significantly associated with organ dysfunction (Relative Risk: 2.71, 95% CI: 1.05-6.99), and presence of at least two signs had a Relative Risk = 4.98 (95% CI: 1.82-13.58). The sensitivity of exam findings ranged from 8-54%, specificity from 84-98%. Signs were associated with increased risk of intensive care and fluid bolus, but not with serious bacterial infection, intravenous antibiotics or admission. Altered mental status and peripheral pulse quality were significantly associated with organ dysfunction, while abnormal capillary refill time and presence of cold, mottled extremities were not. CONCLUSIONS Certain recommended physical exam signs were associated with increased risk of organ dysfunction, a rare outcome in this undifferentiated pediatric population with fever and tachycardia. Sensitivity was low, while specificity was high. Additional research into optimally sensitive and specific diagnostic strategies is needed.
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Affiliation(s)
- Halden F Scott
- Section of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, 13123 East 16th Avenue, B251, Aurora, CO 80045, USA.
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Scott HF, Donoghue AJ, Gaieski DF, Marchese RF, Mistry RD. The utility of early lactate testing in undifferentiated pediatric systemic inflammatory response syndrome. Acad Emerg Med 2012; 19:1276-80. [PMID: 23167859 DOI: 10.1111/acem.12014] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Revised: 06/30/2012] [Accepted: 07/08/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Failure to recognize shock contributes to inadequate early resuscitation in many children with sepsis. Serum lactate levels are used to identify adult patients with septic shock, but physical examination diagnosis alone is recommended in pediatric sepsis. The authors sought to test the utility of lactate testing in pediatric emergency department (ED) patients with systemic inflammatory response syndrome (SIRS). The hypothesis was that early hyperlactatemia (serum lactate ≥ 4.0 mmol/L) would be associated with increased risk of organ dysfunction. METHODS This was a prospective cohort study of children younger than 19 years with SIRS presenting to a pediatric ED. The primary outcome was organ dysfunction within 24 hours of triage; secondary outcomes included disposition, serious bacterial infection (SBI), treatments, and mortality. Study personnel measured venous lactate level on a point-of-care meter, with clinicians blinded to results, and patients received usual care. RESULTS A total of 239 subjects were enrolled; 18 had hyperlactatemia. The hyperlactatemia group had a relative risk of 5.5 (95% confidence interval [CI] = 1.9 to 16.0) of developing 24-hour organ dysfunction. As a test for organ dysfunction, hyperlactatemia had a positive likelihood ratio of 5.0, a sensitivity of 31% (95% CI = 13% to 58%), and specificity of 94% (95% CI = 90% to 96%). Subjects with hyperlactatemia were significantly more likely to receive intravenous (IV) antibiotics and fluid boluses; despite increased therapy, they were at significantly increased risk for intensive care unit (ICU) admission and bacterial infection. CONCLUSIONS Among undifferentiated children with SIRS, early hyperlactatemia is significantly associated with increased risk of organ dysfunction, resuscitative therapies, and critical illness. The addition of serum lactate testing to the currently recommended clinical assessment may improve early identification of pediatric sepsis requiring resuscitation.
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Affiliation(s)
- Halden F. Scott
- Department of Pediatrics; Division of Emergency Medicine; The Children's Hospital of Philadelphia; Philadelphia PA
| | - Aaron J. Donoghue
- Department of Pediatrics; Division of Emergency Medicine; The Children's Hospital of Philadelphia; Philadelphia PA
- Department of Anesthesiology and Critical Care; The Children's Hospital of Philadelphia; Philadelphia PA
| | - David F. Gaieski
- Department of Emergency Medicine and the Center for Resuscitation Science; Hospital of the University of Pennsylvania; Philadelphia PA
| | - Ronald F. Marchese
- Department of Pediatrics; Division of Emergency Medicine; The Children's Hospital of Philadelphia; Philadelphia PA
| | - Rakesh D. Mistry
- Department of Pediatrics; Division of Emergency Medicine; The Children's Hospital of Philadelphia; Philadelphia PA
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Mistry RD, Scott HF, Alpern ER, Zaoutis TE. Prevalence of Proteus mirabilis in skin abscesses of the axilla. J Pediatr 2010; 156:850-1. [PMID: 20303504 DOI: 10.1016/j.jpeds.2010.01.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2009] [Revised: 11/23/2009] [Accepted: 01/07/2010] [Indexed: 11/27/2022]
Abstract
Gram-positive organisms are the most common infectious etiologic agents in skin abscesses. Empiric antimicrobial treatment choices are influenced by this knowledge. In this report, we describe a high prevalence of Proteus mirabilis, a Gram-negative bacillus, in skin abscesses of the axilla, which has potential implications for selection of antimicrobial therapy.
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Affiliation(s)
- Rakesh D Mistry
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Mistry RD, Weisz K, Scott HF, Alpern ER. Emergency management of pediatric skin and soft tissue infections in the community-associated methicillin-resistant Staphylococcus aureus era. Acad Emerg Med 2010; 17:187-93. [PMID: 20370748 DOI: 10.1111/j.1553-2712.2009.00652.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Skin and soft tissue infections (SSTIs) are increasing in incidence, yet there is no consensus regarding management of these infections in the era of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). This study sought to describe current pediatric emergency physician (PEP) management of commonly presenting skin infections. METHODS This was a cross-sectional survey of subscribers to the American Academy of Pediatrics Section on Emergency Medicine (AAP SoEM) list-serv. Enrollment occurred via the list-serv over a 3-month period. Vignettes of equivocal SSTI, cellulitis, and skin abscess were presented to participants, and knowledge, diagnostic, and therapeutic approaches were assessed. RESULTS In total, 366 of 606 (60.3%) list-serv members responded. The mean (+/- standard deviation [SD]) duration of practice was 13.6 (+/-7.9) years, and 88.6% practiced in a pediatric emergency department. Most respondents (72.7%) preferred clinical diagnosis alone for equivocal SSTI, as opposed to invasive or imaging modalities. For outpatient cellulitis, PEPs selected clindamycin (30.6%), trimethoprim-sulfa (27.0%), and first-generation cephalosporins (22.7%); methicillin-sensitive S. aureus (MSSA) was routinely covered, but many regimens failed to cover CA-MRSA (32.5%) or group A streptococcus (27.0%). For skin abscesses, spontaneous discharge (67.5%) was rated the most important factor in electing to perform a drainage procedure; fever (19.9%) and patient age (13.1%) were the lowest. PEPs elected to prescribe trimethoprim-sulfamethoxazole (TMP-Sx; 50.0%) or clindamycin (32.7%) after drainage; only 5% selected CA-MRSA-inactive agents. All PEPs suspected CA-MRSA as the etiology of skin abscesses, and many attributed sepsis (22.1%) and invasive pneumonia (20.5%) to CA-MRSA, as opposed to MSSA. However, 23.9% remained unaware of local CA-MRSA prevalence for even common infections. CONCLUSIONS Practice variation exists among PEPs for management of SSTI. These results can be used to measure changes in SSTI practices as standardized approaches are delineated.
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Affiliation(s)
- Rakesh D Mistry
- Department of Pediatrics and the Division of Emergency Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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Abstract
Serum 25-hydroxycholecalciferol levels were measured longitudinally in a series of breast-feeding mothers and their healthy, term infants for up to 6 months after birth. Although levels both in mothers and infants were lower at 6 weeks' postpartum than at delivery and in cord blood, there was little change thereafter with unsupplemented breast feeding. These findings do not support recommendations for routine supplementation of breast-fed term infants with vitamin D.
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Taliaferro VH, Scott HF. Clinic Atlanta Medical College: Gynæcological. Atlanta Med Surg J 1874; 11:635-639. [PMID: 35825116 PMCID: PMC8846109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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