Documentation of Sepsis in Patients Meeting Pediatric Sepsis Criteria: An Area for Improvement.

OBJECTIVE: Documentation is a critical aspect for properly evaluating a patient's medical status. In order to accurately diagnose sepsis promptly, the need for proper documentation becomes even more necessary. We conducted a retrospective chart review to assess accuracy and frequency of sepsis documentation by electronic medical records (EMR) review. The patients are children aged 0 to 18 years of age in whom the sepsis trigger tool fired in the EMR and were admitted on the inpatient floor or pediatric intensive care unit. METHODS: An EMR sepsis notification alert is currently utilized by our institution. Two pediatric intensivists reviewed the EMR charts of hospitalized, pediatric patients in whom the notification fired. The primary outcome was to identify the patients who met criteria for sepsis according to the 2005 International Pediatric Consensus Conference Guidelines. In patients who met the criteria, physician charting was inspected manually to evaluate documentation of sepsis and/or septic shock within 24 hours of meeting sepsis criteria. RESULTS: Using the 2005 International Pediatric Consensus Conference Guidelines, 359 patients met sepsis criteria. Of those, 24 (7 percent) were documented to have sepsis and/or septic shock in the EMR. Sixteen of those patients had septic shock, while the remaining eight had sepsis. CONCLUSION: Although sepsis is not uncommon, it is often not documented appropriately in electronic medical records. Hypothesized explanations include difficulty in diagnosing sepsis and using alternative diagnoses. This study demonstrates the ambiguity of the current pediatric sepsis criteria and difficulty capturing this diagnosis in the EMR.

A Paranigral VTA Nociceptin Circuit that Constrains Motivation for Reward.

Nociceptin and its receptor are widely distributed throughout the brain in regions associated with reward behavior, yet how and when they act is unknown. Here, we dissected the role of a nociceptin peptide circuit in reward seeking. We generated a prepronociceptin (Pnoc)-Cre mouse line that revealed a unique subpopulation of paranigral ventral tegmental area (pnVTA) neurons enriched in prepronociceptin. Fiber photometry recordings during progressive ratio operant behavior revealed pnVTAPnoc neurons become most active when mice stop seeking natural rewards. Selective pnVTAPnoc neuron ablation, inhibition, and conditional VTA nociceptin receptor (NOPR) deletion increased operant responding, revealing that the pnVTAPnoc nucleus and VTA NOPR signaling are necessary for regulating reward motivation. Additionally, optogenetic and chemogenetic activation of this pnVTAPnoc nucleus caused avoidance and decreased motivation for rewards. These findings provide insight into neuromodulatory circuits that regulate motivated behaviors through identification of a previously unknown neuropeptide-containing pnVTA nucleus that limits motivation for rewards.