Which of the following factors do you think determine mortality or morbidity outcomes from sepsis? Is it: a) Early recognition, b) Early treatment, c) Time to first antibiotics, d) Resuscitation, e) Age and comorbidities or f) All of the above?
If you don’t know the answer, read on. If you do know the answer you should still read on because today’s blog talks about real-life scenarios of paediatric sepsis which according to research, kills more Queensland children than any other illness.
Presenting at the Antimicrobial Stewardship (AMS) Program’s Education Series on paediatric sepsis last month, Clinical Nurse Consultant Amanda Harley from the Queensland Children’s Hospital said sepsis, septic shock and invasive infections in children are on the rise, and early recognition is key.
While the definition of sepsis can be a source of contention, the Stopping Sepsis: National Action Plan (2017) defines sepsis as “... a life-threatening illness that occurs when the body’s response to infection injures tissues and organs.” Amanda goes on to say, “Sepsis is not like other conditions like STEMI for example where clear diagnosis can be made and pathway activation can occur quickly. Whereas the signs and symptoms of sepsis in children are less subtle and very different from one child to the next.”
Amanda describes sepsis as ‘like an iceberg’. “The tip is something you can feel in your gut - that something is not quite right with this patient, but you can’t see what’s lurking ahead. What I ask clinicians is: what are your safety nets to monitor these patients? What do you do if you have a gut instinct about someone?”
The paediatric sepsis Clinical Advisory Group, part of our broader Sepsis Program, have developed and are currently piloting the Paediatric Sepsis Clinical Pathway. “When you get that gut instinct, when you’re not sure, put them on the pathway. Recognise the deteriorating patient.” Amanda says the pathway helps identify signs indicative of organ dysfunction – a clear sepsis ‘tell’. “Look at lactate levels early – higher lactate levels are associated with a higher mortality rate, but bearing in mind you should look at the full clinical picture and not lactate alone. So, get early eyes on the patient. Not everyone who goes on the pathway will have sepsis, so use your clinical judgement, get a senior review. Just ask – could this be sepsis?”
Following Amanda’s presentation, Nicolette Graham (Queensland Children’s Hospital AMS Pharmacist) discussed the antibiotic guidelines included in the Paediatric Sepsis Clinical Pathway.
Nicolette presented the case of a thirteen-year-old male with a history of fevers and confusion. His blood pressure and saturation were unrecordable, he had a temperature of 40.5 degrees Celsius, and a respiratory rate of 45 breaths/minute. Some years prior he had a splenectomy following a push bike injury and was behind with some of his vaccinations.
His biochemistry results showed his organ systems were affected - renal dysfunction and some biochemical derangement. “We thought, could this be sepsis? There were multiple things that triggered our concern and his parents were very concerned. We needed senior eyes on him early and we put him on the pathway.”
Nicolette said there were some components of the pathway that were particularly important – resus (ABCs), IV access, cultures before antibiotics, early appropriate IV antibiotics, early and adequate IV fluid resuscitation, inotropes. “Our time to antibiotics in this case was within 60 minutes – the timeframe we were looking for.” The recognition of the sepsis risk, consideration of parental concern and the early intervention initiated by following the clinical pathway, were what saved this boy’s life.
Amanda and Nicolette’s take-home message? “Just ask – could this be sepsis?”
For more information the AMS Education Series, Queensland Health staff can find their program on the intranet (QHEPS).