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Sepsis, infection and children: what is the message?

In the absence of a nationally agreed paediatric early warning score, James Ashton discusses when to screen for sepsis in children
Picture shows a teenage boy lying in a hospital bed with his eyes closed.

In the absence of a nationally agreed paediatric early warning score, James Ashton discusses when to screen for sepsis in children

Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection . The trouble with sepsis is that anyone with an infection could potentially become septic. There is no single sign, and symptoms vary. In the care of children this is even more difficult.

Studies have been made of the relationship between early warning scores and sepsis escalation. Guidelines from the National Institute for Health and Care

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In the absence of a nationally agreed paediatric early warning score, James Ashton discusses when to screen for sepsis in children

Picture shows a teenage boy lying in a hospital bed with his eyes closed.
Picture: iStock

Sepsis is defined as a ‘life-threatening organ dysfunction caused by a dysregulated host response to infection’. The trouble with sepsis is that anyone with an infection could potentially become septic. There is no single sign, and symptoms vary. In the care of children this is even more difficult.

Studies have been made of the relationship between early warning scores and sepsis escalation. Guidelines from the National Institute for Health and Care Excellence (NICE) say that for the adult population a national early warning or NEWS2 score of 5 or more should instigate a sepsis screen.

With children there is no nationally agreed paediatric early warning score (PEWS) and we are unable to use a score as a primary point of escalation.

The importance of clinical observations

There are other important factors that do not give a number such as those for pre-existing risk. These factors include indwelling lines, neutropenia, recent surgery, being immunosuppressed, skin breaks and an age of under one year.

It is paramount that staff are aware of the potential risks posed by these pre-existing factors in relation to infections and the potential for sepsis to develop.

The debate about one or more red flags in relation to clinical observations is ongoing. The important point concerns clinical observations: are they outside the normal parameters, are there any pre-existing risk factors, is there infection?

This should be the first part of understanding about sepsis for nurses. The complete picture is based on the presentation of the child – in essence, screening for sepsis.

Sepsis screen: try to identify the infection

There is confusion over what a sepsis screen is. For some it is based on the clinical observations, for others it will include blood tests and other microbiology investigations.

Perhaps we should use the term infection screen? Blood cultures, urine, lumbar puncture are all tests to try to identify the infection.

We know there is no one test that will show sepsis, yet we have labelled it as a sepsis screen. The shift to infection screen also prompts a nurse or doctor not to forget about what the source may be.

This is also important when looking at source control and antimicrobial stewardship. We are prompted to act early and quickly, but without the correct investigations we could be giving a long course of intravenous antibiotics (IVAB) unnecessarily.

The golden hour: a more powerful message

The Commissioning for Quality and Innovation (CQUIN) framework advises that where a clinical decision is made to treat a case of sepsis, IVAB should be administered within 60 minutes.

There is a more powerful message, though. As a nurse, if I have raised a concern it is because I am worried about my patient. If a clinician reviews this and agrees, the escalation prompts a quick response.

We both want the best for our patient, and a timely response to clinical interventions such as giving IV fluids, completing the necessary investigations and administering IVAB may prevent further clinical deterioration.

I do the best I can for my patient. This can be difficult with so many other pressures, but as nurses we know we can always ask colleagues for help.

Sepsis training and how we can make a difference

In 2018 my NHS trust mandated sepsis training. I believe awareness and education about sepsis and about the clinically deteriorating patient is a key part of a sepsis pathway.

Teaching nurses and clinicians about sepsis management brings together PEWS, pre-existing risk factors, sepsis/infection screen and the golden hour.

With constant communication, case reviews, feedback and discussions at board and ward level we can make a difference.


James Ashton is a sepsis nurse specialist at Alder Hey Children’s Hospital, Liverpool, and deputy chair of the UK Sepsis Practitioner Forum

 

 

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