ABSTRACT
OBJECTIVES: This study aimed to assess factors related to adherence to the Pediatric Advanced Life Support guidelines for severe sepsis and septic shock in an emergency room (ER) of a tertiary care children's hospital. METHODS: This was a retrospective, observational study of children (0-18 years old) in The Children's Hospital of San Antonio ER over 1 year with the International Consensus Definition Codes, version-9 (ICD-9) diagnostic codes for "severe sepsis" and "shocks." Patients in the adherent group were those who met all three elements of adherence: (1) rapid vascular access with at most one IV attempt before seeking alternate access (unless already in place), (2) fluids administered within 15 min from sepsis recognition, and (3) antibiotic administration started within 1 h of sepsis recognition. Comparisons between groups with and without sepsis guideline adherence were performed using Student's t-test (the measurements expressed as median values). The proportions were compared using chi-square test. p-Value ≤0.05 was considered significant. RESULTS: A total of 43 patients who visited the ER from July 2014 to July 2015 had clinically proven severe sepsis or SS ICD-9 codes. The median age was 5 years. The median triage time, times from triage to vascular access, fluid administration and antibiotic administration were 26, 48.5, 76, and 135 min, respectively. Adherence to vascular access, fluid, and antibiotic administration guidelines was 21, 26, and 34%, respectively. Appropriate fluid bolus (20 ml/kg over 15-20 min) was only seen in 6% of patients in the non-adherent group versus 38% in the adherent group (p = 0.01). All of the patients in the non-adherent group used an infusion pump for fluid resuscitation. Hypotension and ≥3 organ dysfunction were more commonly observed in patients in adherent group as compared to patients in non-adherent group (38 vs. 14% p = 0.24; 63 vs. 23% p = 0.03). CONCLUSION: Overall adherence to sepsis guidelines was low. The factors associated with non-adherence to sepsis guidelines were >1 attempt at vascular access, delay in antibiotic ordering, fluid administration using infusion pump, absence of hypotension, and absence of three or more organs in dysfunction at ER presentation.
ABSTRACT
Trauma remains the leading cause of death for children aged 1 to 14 years. Thoracic trauma is seen in 4% to 6% of pediatric patients presenting to pediatric trauma centers and rarely occurs in isolation. The medical and surgical evaluation of children is a challenging task to even the most experienced physician. Effective treatment of the pediatric trauma patient can only be provided if the physician understands the major pitfalls which are common in the pediatric population. The assessment of the pediatric patient is simplified by an understanding of specific anatomic and physiologic differences between children and adults. While noting children are not small adults, the systematic approach taken towards the evaluation of an adult is similar. Sequential evaluation and management of the ABCs by a caregiver familiar with age specific norms is the most important initial consideration. The care of specific injuries is similar to those found in adults but the patient's size limits the physician's options in many cases.
