The Role of Parental Concerns in the Recognition of Sepsis in Children: A Literature Review

Background: Sepsis is a time critical disease and outcomes strongly depend on time to initiation of appropriate treatment in hospital. A range of studies have assessed sepsis recognition in hospital settings, whereas little is known about sepsis recognition in the community. The decision-making of parents in seeking medical care may substantially impact survival of children with sepsis. An improved understanding of the parental perspective in recognizing sepsis is urgently needed to inform the design of education campaigns and consideration of using parental concerns as a trigger in sepsis screening tools.Aim: To review the literature on parental concerns in the diagnosis of sepsis in children.Methods: A literature review on parental concerns in pediatric sepsis was performed accessing publications in PubMed, CINAHL and Medline published between 1990 and 2018. In addition, we compared guidelines and online institutional sepsis recognition tools and assessed whether parental concerns were used for screening.Results: Out of 188 articles reviewed, 11 met the criteria. One article was found prospectively assessing the diagnostic performance of parental concern in children evaluated for infection, indicating high positive (16.4) and negative likelihood ratio (0.23) for sepsis/meningitis in presence of parental concerns. The role of parental concern was listed as a sign assisting recognition of sepsis in four studies reporting original data, and six reviews commented on parental concern listed as a factor upon diagnosis of sepsis. When comparing selected examples of institutional sepsis pathways available online, parental concern was variably listed as a criterion to prompt evaluation for sepsis.Conclusions: Despite some guidelines emphasizing the role of parental concern in recognizing sepsis, there is a paucity of data in the field. An improved understanding of whether parental concerns adds diagnostic value to sepsis recognition at acceptable sensitivity and specificity is urgently needed. Future prospective studies should assess whether including parental concerns in sepsis screening tools benefits the assessment resulting in early diagnosis and treatment of children with sepsis

Prolonged Postoperative Vasoplegia in Pediatric Patients on Chronic Angiotensin II Blocker Treatment

Prolonged postoperative vasoplegia is known to occur following cardiac surgery in patients on chronic angiotensin II receptor blocker (ARB) treatment in adults. The perioperative management of these drugs in the pediatric population is not well described and here we would like to highlight this fact. While ARBs are increasingly used in children and adolescents with hypertension, there is lack of data to guide optimal pre-surgical management in the pediatric age group. We report two cases of prolonged vasoplegia following cardiopulmonary bypass occurring in adolescent patients on chronic ARB therapy and the importance of cessation of these drugs preoperatively

Validation of an adapted Pediatric Sepsis Score in children admitted to PICU with invasive infection and sepsis: a retrospective analysis of a Dutch national cohort

We validated an adapted form of the Pediatric Sepsis Score (aPSS), a disease-specific severity score available within 60 min of PICU admission, in children with invasive infection. aPSS consist of all components of PSS except lactate. aPSS predicted mortality in children with invasive infection (n = 4096; AUC 0.70 (95% CI 0.67-0.73)) and in children with sepsis (n = 1690; AUC 0.71 (0.67-0.76)). aPSS can be an adequate tool to predict outcome in children admitted to PICU with invasive infection or sepsis, especially in situations where lactate is not available within 60 min. Keywords: Child; Mortality; Organ dysfunction; Score; Sepsis; Septic shoc

Long‐term outcomes after paediatric sepsis (LOTUS)–A protocol for an Australian cohort study

Background: Globally, sepsis has been identified as one of the leading causes of preventable childhood mortality and morbidity. Previous studies on intensive care patients estimated that approximately 30% of children with sepsis experience some form of disability at discharge. Development of care has seen growing numbers of children treated for sepsis not requiring a PICU admission; however, outcomes in this population are yet to be understood. Further focus is required to understand sepsis survivorship across the wider population to address knowledge gaps and morbidity burden in the broader surviving population. Aims: To assess the cognitive, physical, emotional and social health of children surviving sepsis 2 years after hospital discharge. Study design: A prospective, observational cohort study. Results: Two hundred and thirty-two children will be screened, 2 years after their hospital admission, and approached for participation in this study. Children who are <18 years of age at follow-up, treated for sepsis-related organ dysfunction or septic shock in Queensland between October 2018 and December 2019, will be included. Children who are deceased at follow-up, under care of the state, or require English interpreters will be excluded from participation. Data will be collected through an online follow-up survey comprising validated caregiver-reported questionnaires covering the four Post Intensive Care Syndrome-paediatrics (PICS-p) domains (cognitive, physical, emotional and social health; Manning et al. Pediatr Crit Care Med, 2018, 19, 298-300). The primary outcome is an adaptive behaviour of the participants assessed using the Vinelands-3 tool. Secondary outcomes will include neurodevelopment, quality of life, child distress, overall function, executive function, caregiver's distress and caregiver's stress. Analysis of variance (ANOVA), Kruskal-Wallis and Fisher's exact test/chi-squared tests will be used for statistical analyses. No adjustments will be made for multiple comparisons but it is acknowledged that comparisons made in this study are exploratory. Relevance to clinical practice: With more children surviving sepsis, there is a need for a more comprehensive assessment of patient and family outcomes to allow support structures for families leaving the hospital after sepsis. This study is expected to inform clinicians and stakeholders of patient and family well-being after sepsis survivorship

Evaluation of a paediatric clinical ethics service

To evaluate a paediatric clinical ethics service incorporating both normative and empirical analysis.Section 1: Review of consensus guidelines to identify emerging standards for clinical ethics services (CES) and evaluation of the service in relation to these. Section 2: Description of service activity data. Section 3: Feedback from clinical staff involved in clinical ethics consultations was collected using a web-based survey.Four guideline documents were reviewed, and clear emerging consensus standards were identified. Our service fulfils identified knowledge and skill core competencies and at least partially fulfils all of the identified service-level standards. Clinicians report that clinical ethics consultation decreases their moral distress.There is emerging consensus for staff competencies and service-level standards for CES. The role of CES in staff well-being needs to be explored. Collaborative, multi-modal research to develop standards and evaluate CES is needed

Validation of an adapted Pediatric Sepsis Score in children admitted to PICU with invasive infection and sepsis:a retrospective analysis of a Dutch national cohort

We validated an adapted form of the Pediatric Sepsis Score (aPSS), a disease-specific severity score available within 60 min of PICU admission, in children with invasive infection. aPSS consist of all components of PSS except lactate. aPSS predicted mortality in children with invasive infection (n = 4096; AUC 0.70 (95% CI 0.67-0.73)) and in children with sepsis (n = 1690; AUC 0.71 (0.67-0.76)). aPSS can be an adequate tool to predict outcome in children admitted to PICU with invasive infection or sepsis, especially in situations where lactate is not available within 60 min

Educational Outcomes of Childhood Survivors of Critical Illness-A Population-Based Linkage Study

OBJECTIVES Major postintensive care sequelae affect up to one in three adult survivors of critical illness. Large cohorts on educational outcomes after pediatric intensive care are lacking. We assessed primary school educational outcomes in a statewide cohort of children who survived PICU during childhood. DESIGN Multicenter population-based study on children less than 5 years admitted to PICU. Using the National Assessment Program-Literacy and Numeracy database, the primary outcome was educational achievement below the National Minimum Standard (NMS) in year 3 of primary school. Cases were compared with controls matched for calendar year, grade, birth cohort, sex, socioeconomic status, Aboriginal and Torres Strait Islander status, and school. Multivariable logistic regression models to predict educational outcomes were derived. SETTING Tertiary PICUs and mixed ICUs in Queensland, Australia. PATIENTS Children less than 5 years admitted to PICU between 1998 and 2016. INTERVENTIONS Not applicable. MEASUREMENTS AND MAIN RESULTS Year 3 primary school data were available for 5,017 PICU survivors (median age, 8.0 mo at first PICU admission; interquartile range, 1.9-25.2). PICU survivors scored significantly lower than controls across each domain (p < 0.001); 14.03% of PICU survivors did not meet the NMS compared with 8.96% of matched controls (p < 0.001). In multivariate analyses, socioeconomic status (odds ratio, 2.14; 95% CI, 1.67-2.74), weight (0.94; 0.90-0.97), logit of Pediatric Index of Mortality-2 score (1.11; 1.03-1.19), presence of a syndrome (11.58; 8.87-15.11), prematurity (1.54; 1.09-2.19), chronic neurologic conditions (4.38; 3.27-5.87), chronic respiratory conditions (1.65; 1.24-2.19), and continuous renal replacement therapy (4.20; 1.40-12.55) were independently associated with a higher risk of not meeting the NMS. CONCLUSIONS In this population-based study of childhood PICU survivors, 14.03% did not meet NMSs in the standardized primary school assessment. Socioeconomic status, underlying diseases, and severity on presentation allow risk-stratification to identify children most likely to benefit from individual follow-up and support

Antibiotic Exposure of Critically Ill Children at a Tertiary Care Paediatric Intensive Care Unit in Switzerland

Antibiotic overtreatment fosters multidrug-resistance that threatens healthcare systems worldwide as it increases patient morbidity and mortality. Contemporary data on antibiotic usage on tertiary care paediatric intensive care units for in- and external benchmarking are scarce. This was a single-centre retrospective quality control study including all patients with antibiotic treatment during their hospitalization at a paediatric intensive care unit in the time period 2019–2021. Antibiotic treatment was calculated as days of therapy (DOT) per 100 patient days (DOT/100pd). Further, the variables PIM II score, length of stay in intensive care (LOS), gender, age, treatment year, reason for intensive care unit admission, and death were assessed. Two thousand and forty-one cases with a median age of 10 months [IQR 0–64] were included; 53.4% were male, and 4.5% of the included patients died. Median LOS was 2.73 days [0.07–5.90], and PIM II score was 1.98% [0.02–4.86]. Overall, the antibiotic exposure of critically ill children and adolescents was 59.8 DOT/100pd. During the study period, the antibiotic usage continuously increased (2019: 55.2 DOT/100pd; 2020: 59.8 DOT/100pd (+8.2%); 2021: 64.5 DOT/100pd (+8.0%)). The highest antibiotic exposure was found in the youngest patients (0–1 month old (72.7 DOT/100pd)), in patients who had a LOS of >2–7 days (65.1 DOT/100pd), those who had a renal diagnosis (98 DOT/100pd), and in case of death (91.5 DOT/100pd). Critically ill paediatric patients were moderately exposed to antibiotics compared to data from the previously published literature. The current underreporting of antimicrobial prescription data in this cohort calls for future studies for better internal and external benchmarking

Impact of parental and healthcare professional concern on the diagnosis of pediatric sepsis: a diagnostic accuracy study

ObjectiveThe Surviving Sepsis Campaign recommends systematic screening for sepsis. Although many sepsis screening tools include parent or healthcare professional concern, there remains a lack of evidence to support this practice. We aimed to test the diagnostic accuracy of parent and healthcare professional concern in relation to illness severity, to diagnose sepsis in children.DesignThis prospective multicenter study measured the level of concern for illness severity as perceived by the parent, treating nurse and doctor using a cross-sectional survey. The primary outcome was sepsis, defined as a pSOFA score &gt;0. The unadjusted area under receiver-operating characteristic curves (AUC) and adjusted Odds Ratios (aOR) were calculated.SettingTwo specialised pediatric Emergency Departments in QueenslandPatientsChildren aged 30 days to 18 years old that were evaluated for sepsisInterventionNoneMain Results492 children were included in the study, of which 118 (23.9%) had sepsis. Parent concern was not associated with sepsis (AUC 0.53, 95% CI: 0.46–0.61, aOR: 1.18; 0.89–1.58) but was for PICU admission (OR: 1.88, 95% CI: 1.17–3.19) and bacterial infection (aOR: 1.47, 95% CI: 1.14–1.92). Healthcare professional concern was associated with sepsis in both unadjusted and adjusted models (nurses: AUC 0.57, 95% CI-0.50, 0.63, aOR: 1.29, 95% CI: 1.02–1.63; doctors: AUC 0.63, 95% CI: 0.55, 0.70, aOR: 1.61, 95% CI: 1.14–2.19).ConclusionsWhile our study does not support the broad use of parent or healthcare professional concern in isolation as a pediatric sepsis screening tool, measures of concern may be valuable as an adjunct in combination with other clinical data to support sepsis recognition.Clinical Trial RegistrationACTRN12620001340921