Monthly CDI Scenario Discussion – November 2020

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)

0123Score
BehaviorPlaying/
Appropriate
SleepingIrritableLethargic/confused or reduced response to pain
CardiovascularPink; or Cap refill 1-2 secPale/dusky or Cap refill 1-2 secGray/cyanotic, cap refill4 sec/tachycardia (20 above normal)Gray/cyanotic AND mottled or Cap refill> 5 sec or Tachycardia (30 above normal) or bradycardia
RespiratoryWNL>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/

https://www.uptodate.com/contents/septic-shock-in-children-rapid-recognition-and-initial-resuscitation-first-hour

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.

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