Aims NICE (2016) guidance on the recognition, diagnosis and early management of sepsis aims to expedite interventions in children with ‘high-risk criteria’ for sepsis. Early administration of parenteral broad-spectrum antibiotics is recommended in these children, unless a senior decision-making doctor (ST4+) makes an alternative diagnosis with a separate treatment pathway. We assessed the presenting characteristics and management of children at UCLH NHS Foundation Trust (UCLH) Paediatric Emergency Department (PED) following the introduction of these guidelines. A senior decision-making doctor was available for urgent review of children at all times.
Methods We audited the notes of all children presenting to UCLH PED from 6th February to 31 st May 2017 (excluding simple trauma or primarily psychosocial presentation). All notes of children with fever or suspicion of infection and one or more high-risk criterion for sepsis were identified on a daily basis, and data entered onto a specific database. High-risk criteria were as defined by NICE, and included: tachypnoea (≥99 th centile), tachycardia (≥99 th centile), additional oxygen requirement, reduced consciousness, reduced urine output and blood lactate ≥2 mmol/L.
Results 4322 children presented to the PED during the time period. Of these, 216 (5.0%) met one or more high-risk criteria for sepsis. The most common clinical syndrome was viral upper respiratory infection (67 children, 31%). Severe tachycardia was the most prevalent high-risk criterion (159 children, 73%). 25 children (12%) underwent blood testing/IV access, 17 (7.8%) were administered parenteral antibiotics, six (2.8%) were administered intravenous fluid boluses, 16 (7.4%) were admitted to the ward, and one child was transferred to intensive care (in status epilepticus). One child (admitted) had a bacterial pathogen isolated from blood.
Conclusion In this single centre, only 12% of children with one or more high-risk criteria for sepsis underwent blood testing, and 7.8% of children were admitted for parenteral antibiotics. Appropriate de-escalation from the sepsis pathway prevented the admission of an additional two children per day for parenteral antibiotics for presumed sepsis. Given the small proportion of children with high-risk criteria who were deemed to require treatment for sepsis, the availability of appropriately senior decision-making doctors is essential to enable appropriate implementation of these guidelines.
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