Children's Hospitals Today - Summer 2016 - 18

That was in April 2012. The following January, Gov. Andrew M. Cuomo announced "Rory's Regulations," making New York the first state to require all hospitals to adopt best practices for the early identification and treatment of sepsis-the leading cause of death in hospitalized children. Sepsis, often called blood poisoning, is the body's overwhelming and potentially deadly response to an infection. It affects more than 1 million people in the United States each year, according to the Centers for Disease Control and Prevention. This includes more than 40,000 children, 4,500 of whom die each year from the disease and related complications-a higher mortality than pediatric cancer. "Children don't need to die of sepsis," says Joseph A. Carcillo, M.D., professor of critical care medicine and pediatrics at the University of Pittsburgh. "But it's a very complex process because organizationally, there are so many people involved in the care of these children. And culturally, we've come to accept death from sepsis." Layers of complexity Pediatric sepsis experts estimate about 55 percent of patients develop sepsis before they get to the hospital-what starts as a scratch playing basketball in the gym can evolve into something more serious as the immune system overreacts to an infection. This is where pre-hospital surveillance in ambulatory care and emergency response units becomes critical. In other cases, hospitalized patients' underlying conditions, such as cancer, pneumonia or irritable bowel disease triggers sepsis. For some, it may result from a hospital acquired infection. Some cases can be averted by preventing the infection. The key is to detect and treat sepsis when it's present. Severe sepsis and septic shock are the later, most critical stages of sepsis where organs fail, blood pressure drops and patients can die. But pediatric sepsis experts agree these stages do not pose the biggest challenge for children's hospitals because there are guidelines for treatment at these levels. "If you are given the diagnosis of severe sepsis, most children's hospitals will be able to manage it very well," says Charles Macias, M.D., MPH, chief clinical systems integration officer, Texas Children's Hospital in Houston, and national co-chair of CHA's Improving Pediatric Sepsis Outcomes collaborative and the National Expert Advisory Committee. "The big challenge is doing that at a time when the child first presents or first manifests the symptoms-and catching it early." And therein lies the problem because sepsis is often highly elusive in its earliest stage. With typical symptoms that include fever, elevated heart rate and respiratory rate, early sepsis can mimic many other conditions. Some children may not even exhibit these symptoms when sepsis is on the horizon. And, this is one illness where time is always of the essence. "Once you have sepsis, every 30 minutes that goes by that you don't treat the infection, the bacteria double," Carcillo says. "Say it takes eight hours to figure out that the child has sepsis, and then it's doubled 16 times. So, eight hours later, when you've figured it out, the child is very ill." The research shows every hour delay in treatment increases mortality by nearly 8 percent. And, so far in pediatrics, there has been no silver bullet for early detection and diagnosis. "There's not a magic test you can run that says this particular child with a fever and high heart rate has sepsis as opposed to RSV bronchiolitis, for example," says Toni Wakefield, M.D., pediatric hospitalist at Dell Children's Hospital and assistant professor of pediatrics at Dell Medical School in Austin, Texas. "The lack of laboratory tests with 100 percent specificity to tell you this is sepsis hinders our ability to pick out those who have sepsis and those who don't." As a A CLOSER LOOK The stages of sepsis More than 60 percent of pediatric sepsis patients are treated in children's hospitals. Here are the signs of sepsis and how it progresses in pediatric patients. Vasodilation, leaky blood vessels, clots Fever, altered mental state HEALTHY INFECTION ACQUIRED Extreme pain or discomfort SIMPLE SEPSIS Bacterial, viral, parasitic, fungal Systemic Inflammatory Response Syndrome SIRS 18 CHILDREN'S HOSPITAL S TODAY Summer 2016 childrenshospital s.org http://www.childrenshospitals.org

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