Understanding Sepsis Diagnosis in Pediatrics

Reference: Roland D, Munro A. Time for paediatrics to screen out sepsis “screening.” BMJ. June 2023 Date: Sept 12, 2023 Guest Skeptic: Dr. Damian Roland is a Consultant at the University of Leicester NHS Trust and Honorary Professor for the University of Leicester’s SAPPHIRE group. He specializes in Paediatric Emergency Medicine and is a passionate believer and advocate of FOAMed. Damian is also part of the Don’t Forget the Bubbles Team. Dr. Damian Roland Background: For anyone who has ever taken care of a decompensating child with septic shock, it’s unlikely you’ve forgotten the experience. So we have a lot of respect for sepsis and the importance of early recognition to prevent morbidity and mortality. Despite the medical community’s experience with sepsis over the years, there is still much that is unclear about the diagnosis and management of sepsis: How is sepsis diagnosed? What is the optimal fluid to give? How much fluid should be given? When should pressors be started? What pressors should be used? What is the optimal timing of antibiotic therapy? We have covered the topic of sepsis a few times on the SGEM SGEM #371: All of My Lovit, Vitamin C Won’t Work for You SGEM #346: Sepsis-You were Always on My Mind SGEM Xtra: Petition to Retire the Surviving Sepsis Campaign Guidelines SGEM #207: Ahh (Don’t) Push It- Pre-hospital IV Antibiotics for Sepsis SGEM #174: Don’t Believe the Hype- Vitamin C Cocktail for Sepsis SGEM #168: Hypress-Doesn’t got the Power SGEM #92: Arise Up, Arise Up (EGDT vs Usual Care for Sepsis) SGEM #90: Hunting High and Low (Best MAP for Sepsis Patients) SGEM #69: Cry Me a River (Early Goal Directed Therapy) Process Trial Damian and Dr. Alasdair Munro make the bold claim in an opinion article in the BMJ titled, Time for paediatrics to screen out sepsis “screening.” Despite us being very careful in trying to identify children with sepsis, there is a lot of uncertainty. So, we're diving into some of those controversies and gray areas. Some key topics are highlighted below, but tune into the podcast to listen to all the great conversation and pearls of wisdom from Dr. Roland. Why Sepsis is a Challenge in Children’s Acute/Emergency Care? The definition of "sepsis" is not clear. Sepsis may be more due to the body's response to infection than the infection itself. It's possible to have a pathogen in the bloodstream, but not have sepsis because there is not cardiac dysfunction or capillary leakage Children with sepsis may not have a pathogen isolated, and children with a pathogen isolated may not be "septic." What has been the Approach to Sepsis Recognition and Treatment? Sepsis occurs along a spectrum. Recognizing severe sepsis is not difficult in the child that appears acutely ill. Distinguishing the children in the middle of that spectrum is a challenge. There is variation in screening tools and scoring systems for sepsis across healthcare systems. The principle of evaluating for deranged physiology (abnormal vital signs) in combination with fever and infection risk is more ubiquitous. There are differences in application. Screening tools are imperfect. There are many false positives and false negatives. There is no "holy grail" of screening tools. We spoke about the utility of the following in detecting and ruling out sepsis: lactate inflammatory markers (CRP, ESR, procalcitonin) viral PCR testing height of fever We also spoke some of the evidence behind management strategies for sepsis that included: IV fluids Inotropes Antibiotics Recent Controversies and Evidence Many of us are familiar with the Surviving Sepsis campaign/International guidance. After release a group of doctors expressed some concerns due to: conflicts of interest making strong recommendations based on weak evidence criticism regarding the bundling of care that does not c...