First name
Roni
Middle name
D
Last name
Lane

Title

Pediatric Septic Shock Collaborative Improves Emergency Department Sepsis Care in Children.

Year of Publication

2022

Date Published

2022 Mar 01

ISSN Number

1098-4275

Abstract

<p><strong>OBJECTIVES: </strong>The pediatric emergency department (ED)-based Pediatric Septic Shock Collaborative (PSSC) aimed to improve mortality and key care processes among children with presumed septic shock.</p>

<p><strong>METHODS: </strong>This was a multicenter learning and improvement collaborative of 19 pediatric EDs from November 2013 to May 2016 with shared screening and patient identification recommendations, bundles of care, and educational materials. Process metrics included minutes to initial vital sign assessment and to first and third fluid bolus and antibiotic administration. Outcomes included 3- and 30-day all-cause in-hospital mortality, hospital and ICU lengths of stay, hours on increased ventilation (including new and increases from chronic baseline in invasive and noninvasive ventilation), and hours on vasoactive agent support. Analysis used statistical process control charts and included both the overall sample and an ICU subgroup.</p>

<p><strong>RESULTS: </strong>Process improvements were noted in timely vital sign assessment and receipt of antibiotics in the overall group. Timely first bolus and antibiotics improved in the ICU subgroup. There was a decrease in 30-day all-cause in-hospital mortality in the overall sample.</p>

<p><strong>CONCLUSIONS: </strong>A multicenter pediatric ED improvement collaborative showed improvement in key processes for early sepsis management and demonstrated that a bundled quality improvement-focused approach to sepsis management can be effective in improving care.</p>

DOI

10.1542/peds.2020-007369

Alternate Title

Pediatrics

PMID

35229124

Title

Predicting Adverse Outcomes for Shiga Toxin-Producing E. coli Infections in Emergency Departments.

Year of Publication

2021

Date Published

2021 Jan 05

ISSN Number

1097-6833

Abstract

<p><strong>OBJECTIVE: </strong>To assess the performance of a hemolytic uremic syndrome (HUS) severity score among children with Shiga toxin-producing Escherichia coli (STEC) infections and HUS by stratifying them according to their risk of adverse events. The score has not been previously evaluated in a North American acute care setting.</p>

<p><strong>STUDY DESIGN: </strong>We reviewed medical records of children &lt;18 years old infected with STEC and treated in one of 38 participating EDs in North America between 2011 and 2015. The HUS severity score [hemoglobin (g/dL) plus two-times serum creatinine (mg/dL)] was calculated using first available laboratory results. Children with scores &gt;13 were designated as high-risk. We assessed score performance to predict severe adverse events (ie, dialysis, neurologic complication, respiratory failure and death) using discrimination and net benefit (i.e. threshold probability), with subgroup analyses by age and day-of-illness.</p>

<p><strong>RESULTS: </strong>A total of 167 children had HUS, of whom 92.8% (155/167) had relevant data to calculate the score; 60.6% (94/155) experienced a severe adverse event. Discrimination was acceptable overall (AUC 0.71, 95% CI 0.63, 0.79) and better among children &lt;5 years old (AUC 0.77, 95% CI 0.68, 0.87). For children &lt;5 years, greatest net benefit was achieved for a threshold probability &gt;26%.</p>

<p><strong>CONCLUSIONS: </strong>The HUS severity score was able to discriminate between high- and low-risk children &lt;5 years old with STEC-associated HUS at a statistically acceptable level; however, it did not appear to provide clinical benefit at a meaningful risk threshold.</p>

DOI

10.1016/j.jpeds.2020.12.077

Alternate Title

J Pediatr

PMID

33417918

Title

Updates on pediatric sepsis.

Year of Publication

2020

Number of Pages

981-993

Date Published

2020 Oct

ISSN Number

2688-1152

Abstract

<p>Sepsis, defined as an infection with dysregulated host response leading to life-threatening organ dysfunction, continues to carry a high potential for morbidity and mortality in children. The recognition of sepsis in children in the emergency department (ED) can be challenging, related to the high prevalence of common febrile infections, poor specificity of discriminating features, and the capacity of children to compensate until advanced stages of shock. Sepsis outcomes are strongly dependent on the timeliness of recognition and treatment, which has led to the successful implementation of quality improvement programs, increasing the reliability of sepsis treatment in many US institutions. We review clinical, laboratory, and technical modalities that can be incorporated into ED practice to facilitate the recognition, treatment, and reassessment of children with suspected sepsis. The 2020 updated pediatric sepsis guidelines are reviewed and framed in the context of ED interventions, including guidelines for antibiotic administration, fluid resuscitation, and the use of vasoactive agents. Despite a large body of literature on pediatric sepsis epidemiology in recent years, the evidence base for treatment and management components remains limited, implying an urgent need for large trials in this field. In conclusion, although the burden and impact of pediatric sepsis remains substantial, progress in our understanding of the disease and its management have led to revised guidelines and the available data emphasizes the importance of local quality improvement programs.</p>

DOI

10.1002/emp2.12173

Alternate Title

J Am Coll Emerg Physicians Open

PMID

33145549

Title

Predicting Hemolytic Uremic Syndrome and Renal Failure in Shiga Toxin-Producing Escherichia coli Infected Children.

Year of Publication

2019

Date Published

2019 May 24

ISSN Number

1537-6591

Abstract

<p><strong>BACKGROUND: </strong>Shiga toxin-producing Escherichia coli (STEC) infections are leading causes of pediatric acute renal failure. Identifying hemolytic uremic syndrome (HUS) risk factors is needed to guide care.</p>

<p><strong>METHODS: </strong>We conducted a multicenter, historical-cohort study to identify features associated with development of HUS (primary outcome) and need for renal replacement therapy (RRT) (secondary outcome) in STEC-infected children without HUS at initial presentation. Children &lt;18 years who submitted STEC-positive specimens between January 2011 and December 2015 at a participating study institution were eligible.</p>

<p><strong>RESULTS: </strong>Of 927 STEC-infected children, 41 (4.4%) had HUS at presentation; of the remaining 886, 126 (14.2%) developed HUS. Predictors of HUS included younger age (OR: 0.77; 95%CI: 0.69, 0.85/year), leukocyte count ≥13.0x103/μL (2.54; 1.42, 4.54), higher hematocrit (1.83; 1.21, 2.77/5% increase) and serum creatinine (10.82; 1.49, 78.69/1 mg/dL increase), platelet count &lt;250 ×103/μL (1.92; 1.02, 3.60), lower serum sodium (1.12; 1.02, 1.23/1 mmol/L decrease), and intravenous fluid administration initiated ≥4 days following diarrhea onset (2.50; 1.14, 5.46). A longer interval from diarrhea onset to index visit was associated with reduced HUS risk (0.70; 0.54, 0.90). RRT predictors included female sex (2.27; 1.14, 4.50), younger age (0.83; 0.74, 0.92/year), lower serum sodium (1.15; 1.04, 1.27/mmol/L decrease), higher leukocyte count ≥13.0x103/μL (2.35; 1.17, 4.72) and creatinine (7.75; 1.20, 50.16/1 mg/dL increase) concentrations, and initial intravenous fluid administration ≥4 days following diarrhea onset (2.71; 1.18, 6.21).</p>

<p><strong>CONCLUSIONS: </strong>The complex nature of STEC infection renders predicting its course a challenge. Risk factors we identified highlight the importance of avoiding dehydration and performing close clinical and laboratory monitoring.</p>

DOI

10.1093/cid/ciz432

Alternate Title

Clin. Infect. Dis.

PMID

31125419

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