SGEM Xtra: Say What You Need to Say…but Don’t Say “Sepsis Screening”

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Reference: Roland D, Munro A. Time for paediatrics to screen out sepsis “screening.” BMJ. June 2023

Date: Sept 12, 2023

Guest Skeptic: Dr. Damian Roland is a Consultant at the University of Leicester NHS Trust and Honorary Professor for the University of Leicester’s SAPPHIRE group. He specializes in Paediatric Emergency Medicine and is a passionate believer and advocate of FOAMed. Damian is also part of the Don’t Forget the Bubbles Team.

Dr. Damian Roland

Background: For anyone who has ever taken care of a decompensating child with septic shock, it’s unlikely you’ve forgotten the experience. So we have a lot of respect for sepsis and the importance of early recognition to prevent morbidity and mortality.

Despite the medical community’s experience with sepsis over the years, there is still much that is unclear about the diagnosis and management of sepsis:

How is sepsis diagnosed? What is the optimal fluid to give? How much fluid should be given? When should pressors be started? What pressors should be used? What is the optimal timing of antibiotic therapy?

We have covered the topic of sepsis a few times on the SGEM

SGEM #371: All of My Lovit, Vitamin C Won’t Work for You
SGEM #346: Sepsis-You were Always on My Mind
SGEM Xtra: Petition to Retire the Surviving Sepsis Campaign Guidelines
SGEM #207: Ahh (Don’t) Push It- Pre-hospital IV Antibiotics for Sepsis
SGEM #174: Don’t Believe the Hype- Vitamin C Cocktail for Sepsis
SGEM #168: Hypress-Doesn’t got the Power
SGEM #92: Arise Up, Arise Up (EGDT vs Usual Care for Sepsis)
SGEM #90: Hunting High and Low (Best MAP for Sepsis Patients)
SGEM #69: Cry Me a River (Early Goal Directed Therapy) Process Trial

Damian and Dr. Alasdair Munro make the bold claim in an opinion article in the BMJ titled, Time for paediatrics to screen out sepsis “screening.” Despite us being very careful in trying to identify children with sepsis, there is a lot of uncertainty. So, we’re diving into some of those controversies and gray areas.

Some key topics are highlighted below, but tune into the podcast to listen to all the great conversation and pearls of wisdom from Dr. Roland.

Why Sepsis is a Challenge in Children’s Acute/Emergency Care?

The definition of “sepsis” is not clear.

Sepsis may be more due to the body’s response to infection than the infection itself.

It’s possible to have a pathogen in the bloodstream, but not have sepsis because there is not cardiac dysfunction or capillary leakage

Children with sepsis may not have a pathogen isolated, and children with a pathogen isolated may not be “septic.”

What has been the Approach to Sepsis Recognition and Treatment?

Sepsis occurs along a spectrum. Recognizing severe sepsis is not difficult in the child that appears acutely ill. Distinguishing the children in the middle of that spectrum is a challenge.

There is variation in screening tools and scoring systems for sepsis across healthcare systems. The principle of evaluating for deranged physiology (abnormal vital signs) in combination with fever and infection risk is more ubiquitous. There are differences in application.

Screening tools are imperfect. There are many false positives and false negatives. There is no “holy grail” of screening tools.

We spoke about the utility of the following in detecting and ruling out sepsis:

lactate
inflammatory markers (CRP, ESR, procalcitonin)
viral PCR testing
height of fever

We also spoke some of the evidence behind management strategies for sepsis that included:

IV fluids
Inotropes
Antibiotics

Recent Controversies and Evidence

Many of us are familiar with the Surviving Sepsis campaign/International guidance.

After release a group of doctors expressed some concerns due to:

conflicts of interest
making strong recommendations based on weak evidence
criticism regarding the bundling of care that does not consider clinical judgement

Infectious Disease Society of America (IDSA) did not endorse the Surviving Sepsis campaign guidelines due to different interpretation of the major studies that lead to the recommendations.

Our guidelines tend to lack sensitivity and specificity. While there are significant consequences of missing a sepsis diagnosis, the incidence of sepsis is relatively rare.

Why is “Sepsis Screening” an Incorrect Lexicology?

A “sepsis screen” was used to describe a bundle of tests.

In the example of a febrile 6-week old, a “sepsis screen” involves blood culture, urine, inflammatory markers, and possibly lumbar puncture.

The definition evolved when guidance came in that told us what to do if the child presents with certain parameters to evaluate children with a risk of sepsis.

Screening tests should have some key principles:

known denominator of condition being treated
test should be acceptable
test should have good characteristics (clearly identify disease)

Sepsis screening does not meet these criteria.

What can/should we do?

We need to look into the conditions in which decisions are made.

Decisions are often made in very crowded, high pressure environments where staff must see a high volume of patients. We will likely continue to struggle with the problem of identifying sepsis in overwhelmed healthcare systems. Screening tools are not the solution to this. We need to create a system that allows clinicians the time to adequately assess the patient in front of them and make a decision.

On an individual basis, try to think about the trajectory of a patient’s illness in combination with parental concern. Be judicious in deciding on investigations (will it change management?).

The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. So, patients get the best care, based on the best evidence.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

References:

Shankar-Hari M, Phillips GS, Levy ML, et al. Developing a new definition and assessing new clinical criteria for septic shock: for the third international consensus definitions for sepsis and septic shock(Sepsis-3). JAMA. 2016;315(8):775-787.
Nijman RG, Jorgensen R, Levin M, Herberg J, Maconochie IK. Management of children with fever at risk for pediatric sepsis: a prospective study in pediatric emergency care. Front Pediatr. 2020;8:548154.
Gomes S, Wood D, Ayis S, Haliasos N, Roland D. Evaluation of a novel approach to recognising community-acquired paediatric sepsis at ED triage by combining an electronic screening algorithm with clinician assessment. Emerg Med J. 2021;38(2):132-138.