International Consensus Criteria for Pediatric Sepsis and Septic Shock

JAMA · 2024 · 436 citations

• Medicine
• Intensive care medicine
• Internal medicine

Importance: Sepsis is a leading cause of death among children worldwide. Current pediatric-specific criteria for sepsis were published in 2005 based on expert opinion. In 2016, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defined sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, but it excluded children. Objective: To update and evaluate criteria for sepsis and septic shock in children. Evidence Review: The Society of Critical Care Medicine (SCCM) convened a task force of 35 pediatric experts in critical care, emergency medicine, infectious diseases, general pediatrics, nursing, public health, and neonatology from 6 continents. Using evidence from an international survey, systematic review and meta-analysis, and a new organ dysfunction score developed based on more than 3 million electronic health record encounters from 10 sites on 4 continents, a modified Delphi consensus process was employed to develop criteria. Findings: Based on survey data, most pediatric clinicians used sepsis to refer to infection with life-threatening organ dysfunction, which differed from prior pediatric sepsis criteria that used systemic inflammatory response syndrome (SIRS) criteria, which have poor predictive properties, and included the redundant term, severe sepsis. The SCCM task force recommends that sepsis in children be identified by a Phoenix Sepsis Score of at least 2 points in children with suspected infection, which indicates potentially life-threatening dysfunction of the respiratory, cardiovascular, coagulation, and/or neurological systems. Children with a Phoenix Sepsis Score of at least 2 points had in-hospital mortality of 7.1% in higher-resource settings and 28.5% in lower-resource settings, more than 8 times that of children with suspected infection not meeting these criteria. Mortality was higher in children who had organ dysfunction in at least 1 of 4-respiratory, cardiovascular, coagulation, and/or neurological-organ systems that was not the primary site of infection. Septic shock was defined as children with sepsis who had cardiovascular dysfunction, indicated by at least 1 cardiovascular point in the Phoenix Sepsis Score, which included severe hypotension for age, blood lactate exceeding 5 mmol/L, or need for vasoactive medication. Children with septic shock had an in-hospital mortality rate of 10.8% and 33.5% in higher- and lower-resource settings, respectively. Conclusions and Relevance: The Phoenix sepsis criteria for sepsis and septic shock in children were derived and validated by the international SCCM Pediatric Sepsis Definition Task Force using a large international database and survey, systematic review and meta-analysis, and modified Delphi consensus approach. A Phoenix Sepsis Score of at least 2 identified potentially life-threatening organ dysfunction in children younger than 18 years with infection, and its use has the potential to improve clinical care, epidemiological assessment, and research in pediatric sepsis and septic shock around the world.

Racial and Ethnic Differences in Emergency Department Diagnostic Imaging at US Children’s Hospitals, 2016-2019

JAMA Network Open · 2021 · 121 citations

• Medicine
• Pediatrics
• Internal medicine

Importance: Diagnostic imaging is frequently performed as part of the emergency department (ED) evaluation of children. Whether imaging patterns differ by race and ethnicity is unknown. Objective: To evaluate racial and ethnic differences in the performance of common ED imaging studies and to examine patterns across diagnoses. Design, Setting, and Participants: This cross-sectional study evaluated visits by patients younger than 18 years to 44 US children's hospital EDs from January 1, 2016, through December 31, 2019. Exposures: Non-Hispanic Black and Hispanic compared with non-Hispanic White race/ethnicity. Main Outcomes and Measures: The primary outcome was the proportion of visits for each race/ethnicity group with at least 1 diagnostic imaging study, defined as plain radiography, computed tomography, ultrasonography, and magnetic resonance imaging. The major diagnostic categories classification system was used to examine race/ethnicity differences in imaging rates by diagnoses. Results: A total of 13 087 522 visits by 6 230 911 children and adolescents (mean [SD] age, 5.8 [5.2] years; 52.7% male) occurred during the study period. Diagnostic imaging was performed during 3 689 163 visits (28.2%). Imaging was performed in 33.5% of visits by non-Hispanic White patients compared with 24.1% of visits by non-Hispanic Black patients (odds ratio [OR], 0.60; 95% CI, 0.60-0.60) and 26.1% of visits by Hispanic patients (OR, 0.66; 95% CI, 0.66-0.67). Adjusting for confounders, visits by non-Hispanic Black (adjusted OR, 0.82; 95% CI, 0.82-0.83) and Hispanic (adjusted OR, 0.87; 95% CI, 0.87-0.87) patients were less likely to include any imaging study compared with visits by non-Hispanic White patients. Limiting the analysis to only visits by nonhospitalized patients, the adjusted OR for imaging was 0.79 (95% CI, 0.79-0.80) for visits by non-Hispanic Black patients and 0.84 (95% CI, 0.84-0.85) for visits by Hispanic patients. Results were consistent in analyses stratified by public and private insurance groups and did not materially differ by diagnostic category. Conclusions and Relevance: In this study, non-Hispanic Black and Hispanic children were less likely to receive diagnostic imaging during ED visits compared with non-Hispanic White children. Further investigation is needed to understand and mitigate these potential disparities in health care delivery and to evaluate the effect of these differential imaging patterns on patient outcomes.

Racial and Ethnic Differences in Emergency Department Pain Management of Children With Fractures

PEDIATRICS · 2020 · 156 citations

• Medicine
• Medical emergency
• Family medicine

OBJECTIVES: To test the hypotheses that minority children with long-bone fractures are less likely to (1) receive analgesics, (2) receive opioid analgesics, and (3) achieve pain reduction. METHODS: We performed a 3-year retrospective cross-sectional study of children <18 years old with long-bone fractures using the Pediatric Emergency Care Applied Research Network Registry (7 emergency departments). We performed bivariable and multivariable logistic regression to measure the association between patient race and ethnicity and (1) any analgesic, (2) opioid analgesic, (3) ≥2-point pain score reduction, and (4) optimal pain reduction (ie, to mild or no pain). RESULTS: In 21 069 visits with moderate-to-severe pain, 86.1% received an analgesic and 45.4% received opioids. Of 8533 patients with reassessment of pain, 89.2% experienced ≥2-point reduction in pain score and 62.2% experienced optimal pain reduction. In multivariable analyses, minority children, compared with non-Hispanic (NH) white children, were more likely to receive any analgesics (NH African American: adjusted odds ratio [aOR] 1.72 [95% confidence interval 1.51-1.95]; Hispanic: 1.32 [1.16-1.51]) and achieve ≥2-point reduction in pain (NH African American: 1.42 [1.14-1.76]; Hispanic: 1.38 [1.04-1.83]) but were less likely to receive opioids (NH African American: aOR 0.86 [0.77-0.95]; Hispanic: aOR 0.86 [0.76-0.96]) or achieve optimal pain reduction (NH African American: aOR 0.78 [0.67-0.90]; Hispanic: aOR 0.80 [0.67-0.95]). CONCLUSIONS: There are differences in process and outcome measures by race and ethnicity in the emergency department management of pain among children with long-bone fractures. Although minority children are more likely to receive analgesics and achieve ≥2-point reduction in pain, they are less likely to receive opioids and achieve optimal pain reduction.

Racial and ethnic disparities in the delayed diagnosis of appendicitis among children

Academic Emergency Medicine · 2020 · 92 citations

• Medicine
• Pediatrics
• Surgery

BACKGROUND: Appendicitis is the most common surgical condition in pediatric emergency department (ED) patients. Prompt diagnosis can reduce morbidity, including appendiceal perforation. The goal of this study was to measure racial/ethnic differences in rates of 1) appendiceal perforation, 2) delayed diagnosis of appendicitis, and 3) diagnostic imaging during prior visit(s). METHODS: This was a 3-year multicenter (seven EDs) retrospective cohort study of children diagnosed with appendicitis using the Pediatric Emergency Care Applied Research Network Registry. Delayed diagnosis was defined as having at least one prior ED visit within 7 days preceding appendicitis diagnosis. We performed multivariable logistic regression to measure associations of race/ethnicity (non-Hispanic [NH]-white, NH-Black, Hispanic, other) with 1) appendiceal perforation, 2) delayed diagnosis of appendicitis, and 3) diagnostic imaging during prior visit(s). RESULTS: Of 7,298 patients with appendicitis and documented race/ethnicity, 2,567 (35.2%) had appendiceal perforation. In comparison to NH-whites, NH-Black children had higher likelihood of perforation (36.5% vs. 34.9%; adjusted odds ratio [aOR] = 1.21 [95% confidence interval {CI} = 1.01 to 1.45]). A total of 206 (2.8%) had a delayed diagnosis of appendicitis. NH-Black children were more likely to have delayed diagnoses (4.7% vs. 2.0%; aOR = 1.81 [95% CI = 1.09 to 2.98]). Eighty-nine (43.2%) patients with delayed diagnosis had abdominal imaging during their prior visits. In comparison to NH-whites, NH-Black children were less likely to undergo any imaging (28.2% vs. 46.2%; aOR = 0.41 [95% CI = 0.18 to 0.96]) or definitive imaging (e.g., ultrasound/computed tomography/magnetic resonance imaging; 10.3% vs. 35.9%; aOR = 0.15 [95% CI = 0.05 to 0.50]) during prior visits. CONCLUSIONS: In this multicenter cohort, there were racial disparities in appendiceal perforation. There were also racial disparities in rates of delayed diagnosis of appendicitis and diagnostic imaging during prior ED visits. These disparities in diagnostic imaging may lead to delays in appendicitis diagnosis and, thus, may contribute to higher perforation rates demonstrated among minority children.