Implementation of Goal-Directed Therapy for Children With Suspected Sepsis in the Emergency Department

Cruz, Andrea T.; Perry, Andrew M.; Williams, Eric A.; Graf, Jeanine M.; Wuestner, Elizabeth R.; Patel, Binita

doi:10.1542/peds.2010-2895

Cited by 214 publications

(201 citation statements)

References 20 publications

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“…However, there are many barriers to guideline adoption beyond lack of resources, including the perception of restriction of autonomy, biases, lack of familiarity and awareness, lack of outcome expectancy and lack of motivation (20). Our findings are consistent with several studies from the United States of America (USA) showing that even in resource-rich centres, adherence to sepsis guidelines is not achieved for many patients despite a concerted effort by a dedicated team (16,17,21). Together, these data suggest that addressing cultural barriers such as knowledge, behaviour and attitude, in addition to ensuring adequate training and resources, should be key considerations for improving sepsis care.…”

Section: Discussionsupporting

confidence: 85%

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Systems for Pediatric Sepsis: A Global Survey

et al. 2014

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Section: Discussionsupporting

confidence: 85%

“…Specific programmes designed to improve triage processes and sepsis recognition and adherence to goal-directed care have improved outcomes at individual institutions in both resource rich and poor environments (14)(15)(16)(17). At a global level, however, priority areas for research and intervention have not been systematically described.…”

Section: Introductionmentioning

confidence: 99%

Systems for Pediatric Sepsis: A Global Survey

et al. 2014

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“…8 A modification to this approach includes use of a formula to correct heart rate for temperature elevations, but this has not been included in formal definitions. 9,10 Additionally, EDs have adopted screening approaches incorporating only the vital sign criteria from SIRS, because leukocyte counts are not known at the time of triage. 10,11 Prevalence and clinical outcomes of patients with SIRS vital signs are important to understand to appropriately triage and allocate resources.…”

mentioning

confidence: 99%

“…9,10 Additionally, EDs have adopted screening approaches incorporating only the vital sign criteria from SIRS, because leukocyte counts are not known at the time of triage. 10,11 Prevalence and clinical outcomes of patients with SIRS vital signs are important to understand to appropriately triage and allocate resources. Their use to define sepsis suggests that they may define a cohort of patients more likely to require critical care, laboratory testing, and intravenous (IV) treatments.…”

mentioning

confidence: 99%

The Prevalence and Diagnostic Utility of Systemic Inflammatory Response Syndrome Vital Signs in a Pediatric Emergency Department

Scott

Deakyne

Woods

et al. 2015

Academic Emergency Medicine

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ObjectivesThis 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.MethodsThis 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.ResultsThere 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).ConclusionsSystemic 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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“…El empleo de guías para protocolizar el uso de fluidos, antibióticos e inótropos durante la primera hora de atención puede reducir la mortalidad y secuelas neurológicas 26 . Cruz et al 28 , recientemente comunicaron la implementación de un protocolo de tratamiento guiado por metas de reanimación, resultando en una disminución en el tiempo de administración de fluidos y antibióticos, lo cual mejoró la sobrevida de los pacientes.…”

Section: "Tiempo Es Tejido"unclassified

Shock séptico en pediatría II: Enfoque actual en el diagnóstico y tratamiento

et al. 2013

Rev. chil. pediatr.

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Implementation of Goal-Directed Therapy for Children With Suspected Sepsis in the Emergency Department

Abstract: The protocol resulted in earlier recognition of suspected sepsis and substantial reductions in both time to receipt of time-sensitive interventions and a decrement in treatment variation.

Cited by 214 publications

References 20 publications

Systems for Pediatric Sepsis: A Global Survey

Systems for Pediatric Sepsis: A Global Survey

The Prevalence and Diagnostic Utility of Systemic Inflammatory Response Syndrome Vital Signs in a Pediatric Emergency Department

Shock séptico en pediatría II: Enfoque actual en el diagnóstico y tratamiento

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