Think Sepsis – What does that mean?

You may have noticed that there are a lot more paediatric sepsis guidelines flying around these days.  When people write guidelines, they are trying to be helpful but it is always worth knowing why they decided to be helpful.  For example, guidelines for diagnosis of asthma in childhood are strongly motivated by the desire to reduce the overdiagnosis of asthma in childhood.  We know this because the guideline writers tell us.  They're quite good like that.

So what about sepsis?  Well there are two genuine problems that keep coming up around sepsis:
  • Early diagnosis of sepsis
  • Early and aggressive treatment of sepsis
There's probably more to it than that but that is the main thrust of what most sepsis guidelines are trying to achieve.

I think that the guidelines that have come out over the past few years have done a good job in guiding our management of sepsis.  Once you have decided a child has enough evidence of being septic to be treated, crack on and don't spare the horses.  There is no doubt that as a profession, we are getting our act together in this respect.

The first part is more tricky. diagnosing sepsis is difficult.  Sorry, let's be honest, it is really, really difficult.  Sepsis is missed all the time, and I am not talking about the overdiagnosis of missed sepsis which goes like this:

There is a two part truth which guideline writers and readers need to accept.  Sepsis is often missed because it is often easy to miss it.

So, back to the guideline writing - in order to help us diagnoses sepsis, guidelines have been written to help us to recognise sepsis.  As a colleague of mine recently pointed out, that only works if you know to look at the sepsis guideline.  If you are already looking at the sepsis guideline then the battle is already won, because if you are worried enough to look at the sepsis guideline, it's usually time to phone a friend.

So why is it easy to miss sepsis?  There are several reasons;
  • The diagnosis of sepsis is subjective.  There is no mathematical equation (Fever + Tachycardia ≠ Sepsis), test or even definition that gives anyone the answer to the question does this child have sepsis. 2016 saw the third meeting of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine in an attempt to achieve a consensus definition of sepsis.  They will need to meet up again in 2018 if they are going to find true consensus about what sepsis is and what it looks like, since they couldn't quite decide the first three times.  Perhaps they just miss each other that much between conferences.
  • Sepsis doesn't appear, it develops.  There is a reason that we don't have an issue with clinicians missing a diagnosis of croup.  Croup announces its arrival most helpfully.  If only sepsis did the same.  
  • There is almost always another diagnosis to distract the clinician.  As mentioned above, before a child is diagnosable with sepsis, they usually have a prodromal illness.  A classic example of this is secondary sepsis in children with chickenpox.  It is completely understandable that when a child presents with fever and being miserable, having the typical chickenpox rash seems to make the diagnosis obvious.  However, some of these children have sepsis, and it is important to know when that is a strong possibility.
  • All of the features of sepsis are non-specific and can belong to another diagnosis.  Features such as tachycardia are frequently difficult to interpret as a fast heart rate may be due to pain, fear or pyrexia - all of which occur in children who do not have sepsis.  In any case, there is no definition of tachycardia, so we rely on guideline figures.  
  • You can't rely on any one feature to be present all of the time.  Even pyrexia may be absent.  Recognising severe sepsis is relatively easy, but we are being asked to recognise sepsis earlier, before it becomes severe.  That is much more of a challenge.

So, in summary, early sepsis is vague and it is easy to miss because it often hides behind a more obvious diagnosis.  The result is that guidelines are inherently too vague or too prescriptive when it comes to the recognition of sepsis.  Furthermore, if sepsis is not considered, the guideline is of no use whatsoever.

There is relatively simplistic way to deal with all of this.  Since the challenges are mainly about awareness and decision making, I think that a sepsis guideline could simply look like this:

Here are some footnotes on this:
  • Recognising the unwell child starts with recognising the well child.  All sorts of factors are taken into consideration.  While many guidelines emphasise physiological values (heart rate etc.), the behaviour and activity of a child are very important.  The gut feel assessment of the parent and the clinician are also valid.
  • The trajectory of the illness is not always treated with the importance that it deserves.  Children who are not septic often have periods of being subdued but then pick up and have a time where they look and behave as though they are much improved.  This is the "I can't believe how well my child looks now doctor!" effect.
  • Recognising sepsis comes with experience but any clinician can think about the possibility of sepsis.  If you are unsure, get a further assessment.

So, thinking about sepsis is the crucial first step.  It's the deciding that takes the most skill.  Then, when it comes to acting, we should be getting on with with doing whatever we need to do without unnecessary delay.  Hopefully that has made it sound a lot more simple than it really is.

Edward Snelson
Simple is what I need
@sailordoctor

Disclaimer - Simplification is a huge cop out for medical writers, but it's also a lot of fun.  Try it sometime.


Ctrl F and Child Mental Health Problems – Making everything simple

Recently, someone showed me something that has changed my life.  If you press the Ctrl and F keys on your computer (Command +F for Apple) at the same time, a magic box pops up.  This is the 'find' function.  If you don't use it much, you should.  It makes a lot of things much easier.

Here's a non-medical example:  Let's say that you are looking for a payment that you know you made sometime 2-4 years ago from your bank account.  (I don't know, maybe the insurance company want to know how much you bought your laptop for.  Just go with the example please.)  You download the last five years of bank statement from the website and start trawling through for the money that you know that you paid to Amazon for the laptop.  Well stop that.  There is a much easier way.  Press the Ctrl and F keys and then type 'Amazon' in the box.  Hit enter and watch the magic begin.  Using this witchcraft you can find what you are looking for instantly.

Here's a medical example of how I use this function all the time.  Go to the NICE guideline for gastroenteritis in children.  Download the full guideline, not the summary.  Now read it until you find the evidence statement for how the guideline group formulated its decision regarding use of loperamide.  No, don't do that.  The document is over 200 pages long.  Instead use Ctrl and F to start your search, then move on using the arrows (or 'next') until you are where you want to be.

This little trick works for word documents, spreadsheets and anything else.  My favourite trick is to use it on a webpage to find something that I can’t see (like unsubscribe).  Since I was shown how to do this, it has made so many things much easier.  What is amazing to me is that not everyone knows about it.

I don't know what it is like in the rest of the world, but trying to help a child with a mental health problem in the UK can be a lot like trying to find something in a 200 page document.  Primary care clinicians can put a lot of work into trying to help children and young people (CYP) with mental health problems and it can feel like we never get anywhere.  Recently, a child psychiatrist told me a few things that helped to make a lot of sense of these problems and how to help CYP with them, including how to get your referral to the Child and Adolescent Mental Health Services (CAMHS) to get the most appropriate response.

What he told me all made perfect sense.  So I thought you might like to have me share his beautiful and simple insights into child and adolescent mental health problems.

1 - There are usually three factors which lead to children and young people's mental health problems

One of these factors is the child's genetic predisposition.  You can't do anything about that but it is still useful information.

The next factor is the child's environment.  Note that the weight of the domains of a child's environment change as they grow.  For example, the importance of different domains for a 4 year old might look like this:

Then as a child becomes more independent, the importance of each domains changes.
Of course, this is a gross oversimplification, which is exactly what I need in these kinds of circumstances.  By the time you reach adolescence, I suspect the weight that each domain holds over the young person varies greatly, but what the future holds (health, wealth and success or lack of) starts to become much more significant.


The third factor is a trigger.  This brings the intrinsic into contact with the extrinsic factors, precipitating the mental health problem.

2 – Every Child needs an anchor

Children and young people usually have at least one functional and dependable adult in their lives who they can rely on to give them consistency and who will make the CYP feel that they are worthwhile individuals.  A child who never has one of these people in their lives is unlikely to escape mental health disorders.  A child who loses their anchor is at high risk of developing a problem.   Ask, “Who is the most important person in this child’s life?”  If they used to rely on their grandmother who has recently died, this is very important information.

3 – Children and Young People get different mental health problems at different ages

It’s fairly obvious to say that but it does help you when it comes to assessing a problem.  When we are deciding whether something is a mental health problem in the first place, our first question should be, “Is what is happening normal for this age group?”

So what problems do CYP get at different stages?  They get mental health disorders which fit their stage of psychosocial development.  Young children tend to get behavioural problems and neurodevelopmental disorders (oppositional defiance disorder, attention deficit disorder, separation anxiety disorder).  Older children get problems that are related to their transition from child to adolescent (anxiety and self harming).   The top end of the CYP age group (in the UK this goes up to 18 years old) will get the beginnings of adult mental health disorders.

Knowing that something is abnormal doesn’t tell you how significant the problem is.  What tell you the answer to this is the same thing that almost always tells you about how significant a problem is in paediatrics: function.  So, the next question is, “How does this problem impact on the child’s ability to do the things that they want to do or should be able to do?”

And there you have it: your child psychiatry equivalent of the ‘find’ function.  A little understanding goes a long way when it comes to assessing and referring CYP with mental health problems.  Knowing what to ask always brings the best answers.  The answers to these questions just happen to be what a CAMHS consultant needs to see in a referral letter.  By including all of this information, we maximise that consultant’s ability to prioritise you patient.  Sound’s good eh?  So here they are again:


OK, so it’s hardly a keystroke, but considering that we are talking about one of the most complicated problems that we will see in our work, a five question model for getting what you need is pretty good going.

Edward Snelson
Impulsive clinician with a short attention span
@sailordoctor

Acknowledgement - Huge thanks to Girish Vaidya (@DrGirishPsych) who has helped me to understand the core principles of child mental health.  His ability to make the complex simple is a real gift.


If you don’t like what you hear, change the tune. (What to do when you don’t hear a wheeze in a child who should be wheezy)

Every now and then, a clinician will go to see a child who appears to have increased work of breathing and is well (in the way that children with viral induced wheeze usually are) but find no wheeze on auscultation.  How strange!

Making a diagnosis is a complex business.  It is such a complicated process that, most of the time, we don't really think about it at all.  This has been described as type 1 thinking (intuitive) in the context of clinical diagnosis. (1)  Most days, I do very little thinking.  When I come across something unexpected or unfamiliar, I am forced to come out of this unconscious automatic mode and think carefully and consciously (type 2 process) about what is going on.  I have to engage my cortex, and it hurts.

So, going back to this little scenario.  Let's say that the child is 2 years old and has has a cold for 3 days.  They are brought by his parents because they have noticed that his breathing is a little fast.  He looks well and is really quite happy with the toys in your room.  Snot bubbles from his nose as he comes and sits on his mother's knee.  Looking at his chest, he has mild subcostal recession and a mild tachypnoea.  When you listen to his chest, you hear...  breathing.

So, what most people do in this circumstance is to listen some more.  It is traditional to check your stethoscope for gremlins or signs of tampering before pushing the earbuds a bit harder into your ears before listening again.  However, there is no getting away from the fact that there is no wheeze, nor is this the silent chest that is so feared in asthma and viral wheeze.  In a silent chest, no breath sounds can be heard and the patient looks awful.  This child has breath sounds and looks well.

How strange.

The reason that it causes us to have a confused moment is that there are certain combinations of signs and symptoms that indicate a particular illness.  That is particularly useful in children's respiratory illnesses since no one sign or symptom is likely to be specific to an illness.  This is why cough and fever do not equal a lower respiratory tract infection.  We need to look for the presence or absence of other features to form a likely diagnosis.


So what we've got now is a mystery illness.  What causes a well child to have respiratory distress without a wheeze or stridor?
Your next move is simple.  Give the child inhaled (or nebulised if necessary) β-agonists.  I would go with 10 puffs of salbutamol via a spacer device.  Then sit back and watch the magic.

What will probably happen next is a little surprising the first time you experience it: a wheeze appears.  More importantly, the child's breathing improves.  So, what is going on here?

The answer to that would be science.  Science and music are happening and it goes like this:  In order to have a wheeze, there must be the correct conditions for this to occur.  A musical note needs the right amount of air flowing through a tube in the right sort of way.  The size of the tube matters quite a lot.  Ask any wind musician or organ player.

In these cases there is bronchospasm (caused by viral infection) but the conditions are not right to produce a wheeze for you to hear.  Of the parameters that affect the musical note (length of tube, diameter of tube and flow of air) you can change two with β-agonists.  You can't change the length of the tube but the other factors should respond nicely.

So, if you don't like what you hear, change the tune.  When your clinical diagnostic brain tells you that there should be a wheeze, you are probably correct.  If you were expecting a wheeze but don't hear one, by all means rethink your presumption.  If you are left with the same conclusion, then try the β-agonist trick.  It works a treat.

Edward Snelson
Soverynotamusician
@sailordoctor


Disclaimer: This is a very different thing from rechecking a blood pressure until you get the number that you want.  Very different.   Anyway, I would never do that.

Reference
  1. Croskerry P, A universal model of diagnostic reasoning, Acad Med. 2009 Aug;84(8):1022-8.