Sepsis kills. Delayed diagnosis and management of sepsis results in mortality rates that are sometimes higher than 50%. Mismanagement of Sepsis is a major cause of medical malpractice lawsuits.
Recently the American College of Critical Care Medicine has made recommendations that will soon find its way into treatment protocols including Advanced Pediatric Life Support. The recommendations and the particular study from which those recommendations are derived can be seen in the June issue of Pediatrics.
Implementing an emergency department (ED) septic shock protocol and care guideline for children improves compliance with fluid resuscitation and early antibiotic and oxygen administration.
Early recognition of septic shock and early, goal-directed treatment are associated with improved outcomes. The American College of Critical Care Medicine has published practice guidelines incorporated into the American Heart Association Pediatric Advanced Life Support courses. The definition of septic shock in children differs from adults and includes sepsis and cardiovascular organ dysfunction, but hypotension is not required to meet criteria. Care for septic shock that is delivered early in the ED would enhance outcomes.
Recommendation and Study Highlights include:
- Barriers to achieving rapid fluid resuscitation within 30 minutes from triage were addressed, and 3 key elements were identified as goals.
- The electronic database was used to identify patients aged 24 hours to 18 years seen between 2005 and 2007. They were identified with septic shock on discharge according to International Classification of Diseases, Ninth Revision, codes. Patients with trauma were excluded.
- Patients evaluated after implementation of the protocol were identified from 2007 to 2009. The protocol included those who died, those admitted to the PICU, or those with a discharge diagnosis of sepsis but excluded those with trauma.
- Compliance with the protocol was tracked in the following categories: triaged as resuscitation in the ED, attending clinician at bedside within 15 minutes of designation as resuscitation, blood drawn for culture, antibiotics given within 3 hours, fluid bolus given within 1 hour, and blood drawn for lactate measurement in the ED.
- During the study period, 360 pediatric patients with shock were identified and treated in the ED. After exclusions, 345 meeting criteria for septic shock in the ED were analyzed.
- 86.1% met septic shock criteria at the time of triage.
- Mean age of the children was 5.7 years, and 49% were boys.
- There was no difference in the cohort demographic characteristics before implementation or after implementation of the protocol.
- Among the 345 patients, 56.8% had 1 of more complex chronic conditions, and hypotension was documented in 34%.
- The most common clinical findings were tachycardia (73%), tachypnea (66%), and skin color changes (78%).
- Before implementation, compliance with guidelines ranged from 7% to 84%. More than 50% compliance was found for blood draw for culture and timely administration of antibiotics only.
- Throughout the phases of implementation, 68% of patients were admitted to the PICU.
- There was an increase in admissions to the PICU from 60% to 85% after implementation of the protocol.
- The median length of stay in the hospital declined during the study from 181 to 140 hours (P < .05).
- Median hospital and ED costs did not change during the study period.
- Overall mortality rates did not change significantly during the study period (from 7.1% before, to 6.2% after implementation).
- There was a decline in mortality rates among those with 1 or more chronic conditions, from 13.5% to 7.0% after implementation. However, this finding was not statistically significant.
- The authors concluded that implementation of an ED protocol for septic shock in children that included timely feedback was associated with improved processes of care and reduced hospital length of stay.
Clinical Implications
- Among pediatric patients with septic shock, the most likely clinical features are tachycardia, tachypnea, and skin color changes. Hypotension occurs in only one third of these patients.
- Implementation of a septic shock protocol in the ED is associated with improved processes of care and reduced hospital length of stay.
