Topic: Pediatric Sepsis
H&P: Otherwise healthy 3-year-old female presents with fever, nausea, vomiting, tachycardia, and sleepiness for two days. Mom reports child began with nausea and vomiting two days ago, decreased interest in eating and drinking, and yesterday began running fever of 101 with chills. Mom reports child refusing anything by mouth and only wants to sleep.
PMH and Home Medications: None
Vitals: BP 80/58, HR 160, Temp 102.3 orally, Resp 28, Sa02 98% on RA
PE: Patient appears ill with difficulty staying alert
Labs: WBC 18, Procalcitonin 1.8, Creatinine 1.4 (baseline 0.6), Lactic acid 2.8, CXR negative
Treatment/Orders: PICU, IV fluids, Pedialyte, IV antibiotics, and blood, urine, and stool cultures
Discharge Summary: Dehydration and fever due to viral gastroenteritis
Discharge Instructions: Follow up with pediatrician as scheduled. Monitor PO intake
Question: Are there query opportunities based on the scenario stated above?
Discussion: Sepsis is the leading cause of pediatric death worldwide, resulting in an estimated 7.5 million deaths annually. Although current management is based largely on adaptations from adult sepsis treatment, adults and children differ in physiology, predisposing diseases, and sites of infection making it necessary to apply differing diagnostic and management strategies. Find age-specific vitals/labs here https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4913352/ or refer to 2020 ACDIS CDI Pocket guide.
Diagnostic Criteria:
Pediatric SIRS
The presence of at least two of the following four criteria, one of which must be abnormal temperature or leukocyte count:
- Core Temperature of >38.5°C or < 36°C
- Tachycardia, defined as mean heart rate > 2 standard deviations above normal for age in the absence of external stimulus, chronic drug, or painful stimuli; or otherwise unexplained persistent elevation over a 0.5 to four-hour time period, OR bradycardia in children less than 1 year old
- Mean respiratory rate > 2 standard deviations above normal for age or mechanical ventilation for an acute neonate related to underlying neuromuscular disease or the receipt of general anesthesia
- WBC elevated or depressed for age (not d/t chemo) or > 10% bands
Reference: Everette, J. (2019). Improving sepsis documentation in pediatric, neonatal, and newborn cases. ACDIS CDI Journal, 13(5), 30-33, https://acdis.org/articles/archive?publication=1&volume=13&issue=5
Pediatric Acute Renal Failure
AKI is defined by an increase in creatinine by two-fold or greater
- Pediatric RIFLE:
- P(pediatric)-pRIFLE stratifies AKI from MILD to SEVERE based on change in the Serum Cr or estimated creatinine clearance (eCCI). Estimated creatinine clearance (ml/min/1.73m) is calculated using Schwartz formula: eCCI= k x height/SCR
- R= Risk, GFR decreased by 25%; sCr increased by approx. 1.5-fold; <0.5mL/kg/hr for 8 hours
- I= Injured, GFR decreased by 50%, sCr increased by two-fold; <0.5mL/kg/hr for 16 hours
- F= Failure, GFR decreased by 75%, sCr increased by three-fold; <0.3mL/kg/hr for 24 hours or anuria for 12 hrs
- L= Loss, persistent failure > 4 weeks
- E= End-stage renal disease, >3months
Many facilities use the below PEWS form to aide in early identification of sepsis complications in pediatric patients.
PEWS Score Table (Pediatric Early Warning Score)
0 | 1 | 2 | 3 | Score | |
Behavior | Playing/ Appropriate | Sleeping | Irritable | Lethargic/confused or reduced response to pain | |
Cardiovascular | Pink; or Cap refill 1-2 sec | Pale/dusky or Cap refill 1-2 sec | Gray/cyanotic, cap refill4 sec/tachycardia (20 above normal) | Gray/cyanotic AND mottled or Cap refill> 5 sec or Tachycardia (30 above normal) or bradycardia | |
Respiratory | WNL | >10 above normal/accessory muscles use/30+%Fi02 0r 3+L/min | > 20 above normal or retractions or 40+%Fi02 or 6+L/min | >/=5 below normal with retractions /grunting or 50+%Fi02 or 8+ L/min |
Score by starting with the most severe parameters first.
*Score two extra points for every 15-minutes on nebulizers (includes continuous nebulizers) or persistent post-op vomiting
*Use “liters/minute” to score a regular nasal cannula
*Use “Fi02” to score a high-flow nasal cannula*Reference: Monaghan, A. (2005). Detecting and managing deterioration in children. Pediatric Nursing, 17, 32-35. Adapted for use at Children’s of Minnesota
UASI Recommends:
- Query for sepsis
- Query for acute renal failure due to sepsis
- Query for lactic acidosis due to sepsis
Documentation Without Clarification:
- Principal Diagnosis: A084 Viral intestinal infection, unspecified
- Secondary Diagnosis: E860 Dehydration
- Working APR-DRG: 249 Other gastroenteritis, nausea & vomiting
- RW:0.3616 GLMOS:1.96 SOI/ROM: 1/1
Documentation With Clarification:
- Principal Diagnosis: A4189 Other specified sepsis
- Secondary Diagnosis: R6520 Severe Sepsis without Septic Shock, A084 Viral intestinal infection, unspecified, N179 Acute kidney injury, E872 Acidosis
- Working APR-DRG: 720 Septicemia & disseminated infections
- RW:0.5903 GLMOS:3.47 SOI/ROM:2/3
Coding Considerations:
Coding for pediatric sepsis follows adult sepsis guidelines. Additional suggested reading:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6336511/
This is a short synopsis of a possible patient record and is not intended to be all inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.