Session 6 - Lecture 1 - Paediatric Sepsis Flashcards
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3 - Jack Adcock
Jack Adcock died from sepsis
Junior doctor found guilty of gross negligence manslaughter
“sadly, if you put in sepsis and children into BBC website search engine, what you’ll find is at least half a dozen on BBC website, not talking about Daily Mail or Express,
JA case, where a nurse and a doctor were convicted of gross negligence manslaughter bc it was felt they missed guidance of sepsis of this child of Jack Adcock. This was in Leics, it happened in the trust but consequences still felt v strongly amongst Jr Drs - we’ll talk about is why the systems make it difficult to recognise sepsis in children – Jack Adcock is not the only one”
4 - William Mead
Missed chances to save William Mead
NHS 111
Cause of death was sepsis
“Melissa Mead - awarded HM honours for campaigning for awareness of sepsis – find her on UTube for talking about it – silent video about cards talking about sepsis.
[Story] https://amotherwithoutachild.com/my-story/
[Card video] https://www.youtube.com/watch?v=DWOez5w56TU
[This Morning] https://www.youtube.com/watch?v=Vxxr6sJ9P3s
[BBC] https://www.bbc.co.uk/news/health-35403822
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5 - Sam Morrish
Death of Sam Morrish “absolutely shocking”
Shocking failures by the NHS that led to the death of a boy and left his family waiting for answers must not be repeated, David Cameron said
“Sam’s parents were v educated, they’re not medical but they did everything right as a parent, and what happened with Sam is that the health services failed Sam – at pretty much every point of contact from 111 to out of hours - hospital GP to ambulance to local hospital and even the paediatric dpt in tertiary hosp [primary care = GP; secondary care = local hospital; tertiary care = specialist hosp after referral from secondary care].
https://www.bbc.co.uk/news/uk-england-devon-28133687
“
6 - Sepsis Death Reports
Time to act 2012, Health Ombudsman
10 cases that were brought to her where there were serious failings in care. 1 example was a child.
Why Children Die 2008.
Child death reviews demonstrating significant problems with recognising the sick child.
An avoidable death of a three-year-old child from sepsis 2014, Health Ombudsman
A report on an investigation into a complaint from Parents
“3 really important reports to know about, if interested, worth a read, particular #3.
- Published by Dame Judy Mellor – Health Ombudsman for parliament – basically if you have a complaint, she’s the most top person. So saw many ppl who died from sepsis, getting complained about it and she looked where the problems were.
https: //www.ombudsman.org.uk/sites/default/files/2016-08/FINAL_Sepsis_Report_web.pdf - Review of children who died within the country, confidential enquiry into child death, done in 2006 and published in 2008 - so known for a while, not new - talks about maybe 25% of children who die have modifiable factors within their care
https: //www.publichealth.hscni.net/sites/default/files/Why%20Children%20Die%20-%20a%20pilot%20study%202006.pdf - Report into Sam Morrish’s death - recommend reading this one most – it charts how systems as a whole can fail the pt
https: //www.ombudsman.org.uk/sites/default/files/An_avoidable_death_of_a_three_year_old.pdf
https://www.ombudsman.org.uk/”
7 - Avoidable factors sepsis
The most significant recurrent avoidable factor between cases was a failure to recognise severe illness in children. This most often occurred at the point of first contact between the sick (and often febrile) child and healthcare services…
“This is possibly the most important learning point from all those reports (slide 6) – which is, the most notable avoidable factor was failure to recognise child was unwell – and this was mostly at first point of contact of health services, this then leads to a delay and a cascade of other problems.
febrile = fever
8 - Case 1
Example case of a child
PHOTO OF A CHILD IN HOSPITAL ON OXYGEN
13 month old boy presented to hospital, had fever every day for 5 days, snot everywhere, came right down his front. Was thought that this was a viral illness, but on the 5th day, he was still having fevers, v lethargic, wasn’t really himself at all – was drinking milk but the morning he took his bottle he was looking blue and grey and mottled, and so, his parents took him to hospital.
Example case of a child
PHOTO OF A CHILD IN HOSPITAL ON OXYGEN
“So this is real life, this is ‘G’ – he was 13 months, and he presented to hospital, had fever every day for 5 days, snot everywhere, came right down his front. Was thought that this was a viral illness, but on the 5th day, he was still having fevers, v lethargic, wasn’t really himself at all – was drinking milk but the morning he took his bottle he was looking blue and grey and mottled, and so, his parents took him to hospital.
Now keep this img in your head as you go through the talk bc I’ll come back to G at the end and ask you what you think should or would have happened to G when he went to hospital”
9 - Call it what it is
Call it what it is
PHOTO OF A DUCK
“This is a duck, and you’re thinking, well it’s bloody obvious it’s a duck. And this is one of the problems with sepsis; is it’s not always obvious, but when it is obvious, we don’t always use the word sepsis – we don’t call it sepsis, it’s not a concept that has been widespread e.g. we talk about pnemonias, UTIs, neural sepsis, biliary sepsis – all sorts of infections, but we don’t actually associate those things with the concept of what it actually is.”
10 - ‘Glass test’
Spotting Meningococcal sepsis: The ‘glass test’
PHOTO OF THE ‘GLASS TEST’ FOR MENINGOCOCCAL RASH
“Glass test for rash that is non-blanching which is indicative of meningococcal disease or meningococcal sepsis. We know this is a life-threatening condition. Many years ago used to see this probs 1 a month, and now, not even see one in in 2 years, not with meningococcal bacteria – we now see diff disease, pneumococcal [meningococcal??] disease or example. But we’ve come a v long way in mngmt of meningococcal disease - part of that is due to vaccinations for meningitis – there are at least 4 diff ones you can get vaccinated against now, and that has meant that we now see v little of it, thankfully, bc it’s a devastating disease. The other things we’ve learnt is the public awareness. So meningitis foundation campaigned tirelessly to public about what this is – taught to health visitors to new parents, in red book, news, papers, in GP practices etc – so there’s public awareness. But this is easy bc it’s a v identifiable symptom or sign that ppl can latch onto - so If a GP sees this you’ll immediately get a shot of penicillin on the backside before you even leave the practice to the hosp. If a parent sees this go straight up to ED in hosp and get fast tracked through. This is easy.”
[Press a clear glass tumbler firmly against the rash. If you can see the marks clearly through the glass seek urgent medical help immediately]
11 - Why is sepsis hard to identify?
Identifying sepsis from other causes
PHOTO OF SEPSIS WORD CLOUD
“The problem with sepsis is picking out sepsis out of this jungle of other things – bc signs of sepsis are basically same as everything else, so it’s really really hard - we don’t have a specific test to diagnose sepsis or clinical sign to point towards it so it’s a hard job. “
12 - Adult & child sepsis
Adult sepsis definitions
PHOTO OF AN ADULT
“2 definitions between adult and paediatric sepsis - adult def changed couple of years ago”
13 - Adult sepsis origins
JAMA
The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).
MERVYN SINGER ET AL. JAMA. 2016;315(8):801-810.
DOI:10.1001/JAMA.2016.0287
“Adults now onto sepsis 3, fairly international consensus definition. Why do we need to know how to define sepsis? Lots of people died from infections, certain features such as organ failure then multi organ failure then they die – so they thought need to research this. So lots of research scientists, how are we going to pick out the pts - well we think it’s something to do with inflammation (e.g. pallor calor dolor rubor tumour; pain redness swelling heat etc.) – looked at these signs and symptoms, but what are the things that shows your bodies have these signs – therefore these definition for sepsis – but they were never designed for the diagnosis – these were identified post hoc so they could do studies on. Now, couple of years ago, we know a lot more about sepsis. This paper was based on big data we now have (~27,000 pts with sepsis) – so they’ve wanted something a bit moire predictive of what’s going to happen to you - looked at these pts and pts who’ve died, looked at factors and parameters to come up with a model of who were more at risk of dying from these severe infections.”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4968574/
14 - Adult Sepsis Definition Learn
New Sepsis Definition (Adults) Infection Dysregulated host response Life threatening organ dysfunction
“And this is the new definition that they’ve come up with, which is: You have a infection that causes a dysregulated host response in the body – your cytokine response, your white cells fighting infection, the infection isn’t contained in one area anymore, it becomes disseminated - so the cytokines that are being released where the infection is is causing problems elsewhere in the body e.g. cellulitis in your foot but cytokines causing effects in your lungs leading to respiratory distress. This leads to dysregulated host response causing organ dysfunction which can, if not treated, lead to death.”
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Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. For clinical operationalization, organ dysfunction can be represented by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more, which is associated with an in-hospital mortality greater than 10%. Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia. This combination is associated with hospital mortality rates greater than 40%. In out-of-hospital, emergency department, or general hospital ward settings, adult patients with suspected infection can be rapidly identified as being more likely to have poor outcomes typical of sepsis if they have at least 2 of the following clinical criteria that together constitute a new bedside clinical score termed quickSOFA (qSOFA): respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4968574/
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