A New Tool to Help Screen for Sepsis in Kids?
/Georgette N, Michelson K, Monuteaux M, Eisenberg MA. Development of a New Screening Tool for Pediatric Septic Shock. Ann Emerg Med 2024;
Big Picture
Current screening tools for pediatric septic shock and sepsis are highly specific but lack sensitivity. This study substituted age adjusted vital sign measures and a pediatric shock index into currently existing pediatric sepsis scoring systems to create the qPS4.When utilizing a cut off of ≧ 2 points, the qPS4 was highly sensitive and specific, and identified pediatric septic shock far sooner into a patient's course.
A Brief Sepsis Overview
Sepsis is a topic that is ever changing in the literature. In adults, there are two criteria/scoring systems that are commonly used in the evaluation of patients presenting with concern for sepsis SIRS and qSOFA. SIRS criteria are often used to identify patients who are developing sepsis, while the qSOFA is used to predict mortality from sepsis.
Sepsis in Pediatric Patients
Currently existing scoring systems for the evaluation of pediatric sepsis include the pediatric qSOFA, LqSOFA and TAMSI. A brief explanation of the variation of these scores is included below.
Pediatric qSOFA = qSOFA with age adjustment for vital sign metrics
LqSOFA = qSOFA w/ substitution of age adjusted heart rate and capillary refill for SBP metric
TAMSI = pediatric shock index calculated with heart rate, temperature and MAP
Importantly, these scores are relatively similar in their high specificity, but have low sensitivity for evaluating pediatric patients with concern for sepsis, and development of septic shock
Development of the Quick Pediatric Septic Shock Screening Score (qPS4)
The qPS4 was derived by:
Replacing the age adjusted heart rate from LqSOFA with the TAMSI
Modifying age adjusted respiratory rate cut offs with empirically derived cut offs.
Data was obtained from the first 6 hrs of ED arrival and the “worst” values included. Score ranges from 0-4 points
Quick Pediatric Septic Shock Screening Score (qPS4). from Georgette N, Michelson K, Monuteaux M, Eisenberg MA. Development of a New Screening Tool for Pediatric Septic Shock. Ann Emerg Med 2024;
Study Design
Validation of the qPS4 was performed as part of a retrospective cohort study of pediatric patients presenting to a tertiary academic emergency department between the ~9 year study period (01/01/2012 - 12/31/2021).
Inclusion/Exclusion Criteria
Age: 1 month -18 years old
With a suspected infection
Temp < 36 ℃ or > 38 ℃
Administration of non-topical abx
Microbial testing of any kind
As qPS4 is vital sign based, patients were excluded if they were transferred from an outside hospital or if vital signs were not recorded.
Primary Outcome: Development of Septic Shock (defined as suspected infection, administration of antibiotics and vasoactive medication)
For each patient in the study group, a qPS4, pediatric qSOFA and LqSOFA score was calculated to compare sensitivity and specificity.
Results
The study included a validation cohort of >47,000 patients. The primary outcome (development of septic shock) was present in 0.3% of patients.
At a cut off ≧ 2 the qPS4 had the following test characteristics.
Sensitivity of 89.7%
vs. LqSOFA 56.1%
vs. pSOFA 43.9%
Specificity of 92.2%
vs. LqSOFA 96.8%
vs. pSOFA 95.5%
Negative LR 0.1
Positive LR of 11.6
Overall the qPS4 had similar specificity with a much improved sensitivity. Interestingly, the qPS4 had shorter time to diagnosis compared to other scores with an average time to “positive test” (i.e. score ≧ 2 for qPS4) of 0.7 hours vs. 2.5 hrs for pediatric qSOFA. It is important to note that the sensitivity and specificity reported above is an average for all age groups and when looking at the test characteristics for each individual age group, the test performed poorly in infants (1-11 months old). This appears to be similar to the test characteristics of LqSOFA and pediatric qSOFA, once again highlighting the tricky nature of babies.
Limitations
Vital sign based assessments can always be clouded by the possibility of human error, particularly, when assessing respiratory rate. The direct comparison of sensitivity/specificity of each scoring system can be confounded by the fact that the scores were developed with different primary outcomes, for example the qPS4 predicts development of shock versus the pediatric qSOFA predicts admission to ICU. Finally, while the study attempted to control for confounders, such as increased respiratory rate from asthma or sedation from alternative etiologies, the vital sign abnormalities in the study population may have been caused by other “sepsis mimics” that the team did not control for.
Take Home
Comparatively to other sepsis scoring systems for pediatric patients, the qPS4 has improved sensitivity without sacrificing specificity. It is relatively easy to obtain, with no laboratory data required (in comparison to other recently developed scores, such as the Phoenix score), making it widely applicable to ED physicians practicing in all environments.
Authorship
Written by Alessandra Della Porta, PGY-3, University of Cincinnati Department of Emergency Medicine.
Peer Review, Audio Editing, Posting by Jeffery Hill, MD MEd, Associate Professor, University of Cincinnati Department of Emergency Medicine
Cite As: Della Porta, A. Hill, J. A New Tool to Help Screen for Sepsis in Kids? TamingtheSRU. www.tamingthesru.com/blog/2024/10/31/a-new-tool-to-help-screen-for-sepsis-in-kids. 10/31/24.
