Sepsis and Self-doubt #WILTW

This is the 113th #WITLW

Simon is 18 months old. He has had a cold for a couple of days but on waking his mother finds him to be pale, clingy and not his usual self. He refuses any food and while nestled in his mothers arms appears to become very listless. An ambulance is called and Simon is brought to the Emergency Department. 

He is seen on arrival and noted to be flushed and quiet with a raised respiratory rate (42 breaths per minute) and a high heart rate (165 beats per minute). There is no rash but his hands and feet feel cold. His temperature is 40.1 degrees centigrade. He’d spat out the paracetamol his mother had tried to give him in the morning. 

This child has some  features consistent with being high risk for sepsis. Sepsis is a devastating disease which can rob families of their loved ones in a matter of hours. It makes little differentiation between young and old, and can be as subtle as it is obvious in its presentation. Too often patients are let down because it is not considered, or acted on, promptly.

This week saw the release of the NICE (National Institute for Health and Care Excellence) Sepsis guidance. It is a detailed guide to recognition and initial management, stratified across different age ranges, both in and out of hospital. Families who have lost their children to sepsis , especially those in whom it appears that opportunities were missed to intervene, should welcome the advice it offers. However not treating for sepsis may well be one of the biggest challenges I face in Paediatric Emergency Medicine.

The vast majority of children I see do not have sepsis. It is very important to emphasise that in an era of wide spread vaccination, the rate of serious infection, not even the more serious sequelae of sepsis, in those over 3 months will be less than 7%. Given that febrile illness is the second most common presentation to Emergency Departments (after breathing difficulty) it is easy to see why finding the ‘sepsis’ needle in the ’emergency department’ haystack is an often used phrase.

Needle in haystack

What of Simon and his need for urgent blood tests and antibiotics for his potential sepsis? Simon also has a snotty nose, his throat is red and his ears inflamed. I see in his eyes an awareness of his surroundings. There is a bloody mindedness to the way he tries to push away the paracetamol he is offered and eventually takes. While his peripheries are cool his head and body are very hot and the perfusion of blood to the skin here is normal. While his mother entirely appropriately worries about him,  my instinct is that he does not have a serious infection.

But is my instinct sufficient to fulfil a duty of care to my patients and provide them with the most evidenced based treatment? This is the dilemma I face on an almost daily basis. It is simply not possible to treat all the patients I see who fit some form of criteria as having sepsis. So I remain plagued by self-doubt in my decision making. Will this be the case where I drop the ball and destroy a families life because my gut instinct felt it was just a virus?

My hope it is this self-doubt that keeps patients safe. Guidance like that produced by NICE is essential to provide a framework we can all work to. Awareness raising for professionals and the public like that performed by the UK Sepsis Trust is also vital to ensure knowledge translation occurs at scale. But underpinning everything will be individual health care professionals who must continue to doubt and reflect on their decisions to ensure Simon remains a healthy child and not another preventable tragedy.

Think: Could this be Sepsis? 

What have you learnt this week? #WILTW

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5 thoughts on “Sepsis and Self-doubt #WILTW”

  1. And as you well know the essential safety netting with written and verbal advice on when to seek further help and an acknowledgment that things may change and develop is essential. We should give a firm diagnosis if there isn’t one- we should be honest and say we aren’t sure what the issue is but we don’t think it needs further treatment and investigation at present. If things change families should seek further help- preferably from someone who saw the child the first time so they can see any change.
    It’s important we don’t over treat unnecessarily as we will increase antibiotic resistance and our hospitals will be full to the brim. Equally we must not miss the child who is trying to tell us they are septic- often picked up by our gut rather than any one specific factor. Finally we must face the uncomfortable truth that children will be well in the evening and sadly pass away the next day- and there will be nothing we could have done differently. Many of us have seen invasive group A strep turn a talking laughing child into one who is unable to survive despite medicines best intentions. Maybe one day in the future we’ll be able to stop those- but until then awareness, structured review and sensible Ab prescribing are our best tools. #thinksepsis

    1. Simon, bless him, never really existed but is a fairly close representation of patients we see on a regular basis. After a period of observation his observations all settled and he returned to his normal self. Mum was happy to take him home having been given clear advice on when to return if certain features of illness developed.

  2. I agree with this Damian. My concern about the paediatric sepsis 6 and the NICE guidelines are they could very easily lead to an increase in IV antibiotic use and hospital admissions without any reduction in children dying from sepsis. Sepsis awareness is great but I think a lot of cases driving the campaigns did not arise because sepsis wasn’t considered. It was missed because the tools we use to detect it aren’t good enough.

    In my view until we have a point of care test for sepsis which is sensitive and specific we will continue to miss sepsis regardless of how many guidelines are written. This is where I would direct funding, not on unproven awareness campaigns.

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