Evaluation of the use of septic shock early diagnosis and differentiation guide in the pediatric emergency department

Introduction-Objective: Sepsis is a clinical syndrome characterized by systemic inflammatory response accompanied by immune system abnormality triggered by infection, microcirculation disorder, and end-organ failure. Sepsis and septic shock in children, when overlooked, pose a clinical problem leading to mortality and significant morbidity. Delay in the diagnosis of sepsis is one of the most important factors contributing to mortality and morbidity. Making a diagnosis of sepsis, septic shock criteria, and defining sepsis is a complex and time-consuming process that also requires waiting for laboratory results. Therefore, the use of clinical rapid triage-based guidelines for early sepsis diagnosis and optimization of these guidelines in each unit is necessary. Therefore, in this study, we planned to evaluate the use of the early recognition and differentiation guide for septic shock recommended in 2020 and its effectiveness by comparing it with the criteria for sepsis, septic shock in children in the emergency unit of the Akdeniz University Faculty of Medicine. Materials-Methods: In our study, 350 patients under the age of 18 who applied to the Akdeniz University Hospital Pediatric Emergency Unit between 01.02.22-01.08.22 and agreed to participate were prospectively evaluated observationally. Pediatric patients included in the study according to the criteria determined over a 2-year period were evaluated by a pediatric emergency service triage nurse trained in the early recognition and differentiation of sepsis and septic shock steps according to the pediatric emergency service triage area, then evaluated by a pediatric emergency service assistant and a pediatric emergency service senior. The management of patients was continued according to routine pediatric emergency service practices. Data reviews were conducted from file records based on outpatient follow-up, daily emergency observation, and decisions for admission to pediatric wards or pediatric intensive care units. Patient data were evaluated for sepsis diagnosis according to the criteria for sepsis, septic shock. Data related to sociodemographic, clinical, laboratory, follow-up, and outcome characteristics of patients were recorded and collected on the study form. Results: Between February 1, 2022, and August 1, 2022, 350 patients under 18 years of age who presented to the Pediatric Emergency Unit of Akdeniz University Hospital with suspicion of infection and/or body temperature abnormalities were included in the study. The median age of the 350 patients in our study was 60 months, with a wide age range. 8.6% of the patients had an underlying chronic disease, and 16 of these 30 patients exhibited immunosuppressive characteristics. Upon initial evaluation by the pediatric emergency triage nurse, only 4.6% of the patients were found to be in poor general condition, and 27.4% had a fever above 38 degrees. A total of 69 out of 350 patients had a fever of 38 degrees or higher. Physicians found that 13.7% of the patients had a fever, 0.3% had pathological blood pressure changes, 18.3% had tachycardia, 8.9% had pathological respiratory findings, and 4.3% had prolonged capillary refill time. Cardiovascular system dysfunction was identified in 0.3% of the patients requiring vasoactive drugs, 2.6% with persistent acidosis, 1.4% with significantly prolonged capillary refill time, and 0.3% with a central-peripheral temperature difference. Three patients (0.9%) met the criteria for septic shock. Of the patients flagged by the short sepsis package as suspected of sepsis, 55.6% were monitored in the yellow or red areas by nurses, and 67.8% by physicians, who conducted further evaluations or interventions. Among the 204 patients deemed not suspected of sepsis by the short sepsis package, 81.9% were assigned to green triage by nurses and 62.3% by physicians. After initial evaluation, 1.7% of patients received resuscitation based on the senior physician's clinical decision, and 0.3% of patients died. 0.9% required intensive care, 8.3% required inpatient care, and 88% were discharged in good condition. All patients diagnosed with sepsis based on consensus criteria were also identified as suspected sepsis cases by the short sepsis evaluation package. Similarly, all patients diagnosed with septic shock based on consensus criteria were flagged as suspected sepsis by the short sepsis package. None of the patients not flagged by the short sepsis package were diagnosed with septic shock based on consensus criteria. Conclusıon: The concordance between physicians and nurses in evaluating patients flagged by the short sepsis evaluation package in the yellow and red triage areas was moderate. Without underlying disease, the short sepsis package criteria were mostly accurate in green, yellow, or red coding by physicians and nurses. The difference in using the short sepsis package for patients with underlying disease was not statistically significant for both physicians and nurses. According to consensus criteria, 22.3% (78 patients) of the 350 patients met the definition of sepsis, and only 0.9% (3 patients) met the definition of septic shock. Based on nurse triage data, the short sepsis/septic shock recognition and differentiation package identified suspected sepsis in only 24 (8.6%) of the 350 patients. The package's indication of sepsis suspicion significantly influenced the specialist's decision for resuscitative intervention and observation. However, the limited sample size and the small number of patients requiring resuscitative intervention limit this interpretation. When comparing the short sepsis evaluation package with consensus criteria, the package predicted the presence and absence of sepsis. It was observed that physicians and nurses could distinguish critical from non-critical patients in the non-risk group using the short sepsis package. The short sepsis evaluation package improved sepsis recognition in the absence of underlying disease but failed to distinguish patients without sepsis.