It might start out looking like not much more than an ordinary childhood fever.
But within days — within hours, sometimes — the complication known as sepsis can turn deadly. The patient's blood pressure dives. Intense pain floods her body. Her organs begin to shut down.
The toll is frightening: Sepsis hospitalizes some 75,000 children and teens each year in the United States. Nearly 7,000 will die, according to one 2013 study. That's more than three times as many annual deaths as are caused by pediatric cancers. And some of the children who survive sepsis may suffer long-term consequences, including organ damage and amputated limbs.
Now dozens of hospitals nationwide, including in Fort Worth, are launching an all-out campaign against sepsis, an infection-related complication which can take hold after a viral illness — or an injury as innocuous as a scraped arm or a bug bite. Their ambitious goal: Reduce both childhood sepsis deaths and diagnoses of severe sepsis at participating hospitals by 75 percent by the end of 2020.
"You go big or you go home," said Amy Knight, chief operating officer for the Children's Hospital Association, which organized the sepsis collaboration.
The 44 hospitals participating in the effort so far — more are likely to join — have agreed to implement diagnostic and treatment protocols developed by dozens of experts. They will, for instance, screen all patients who show any signs that could be associated with sepsis and treat potential cases with quick infusions of antibiotics and intravenous fluids. And they'll submit data on their cases to the collaboration — including how fast they got patients into treatment — in hopes of identifying best practices.
Some hospitals are also working on public education, such as teaching the warning signs of sepsis to parents of cancer patients, who are especially vulnerable to infection.
One key challenge: Training physicians and nurses to more quickly recognize the earlier stage, known as "warm sepsis," which can masquerade as many other more common and far less worrisome childhood ills.
A child might develop a fever and a somewhat faster heart rate, but otherwise has good color and is chatting with the doctor. "And 10 minutes later, their blood pressure is out the bottom and they are in dire straits," said Dr. Joann Sanders, chief quality officer at Cook Children's Health Care System here in Fort Worth. "A kid who is well into sepsis is not that hard to recognize. That warm sepsis kid — that's your challenge."
A terrifying brush with death
Sepsis moved with terrifying speed in the case of Chloe Miller, who was diagnosed with septic shock last fall at age 12.
Chloe had gone to school near her home in Silver Spring, Md., that Friday with no signs of illness, although the teachers reported that she seemed somewhat tired, recounted her dad, Mark Miller. Her parents have learned to stay particularly attuned to even subtle changes in Chloe, who has autism and a seizure disorder and can't communicate verbally.
By Saturday, the preteen was running a fever of 104 degrees. Acetaminophen did bring it down. But she was sleeping for long stretches, and becoming increasingly difficult to wake up. Alarmed, Chloe's mother and grandmother decided to take her to a local emergency room late Saturday. They nearly had to carry her to the car.
The doctors and nurses there moved quickly, diagnosing Chloe with pneumonia and influenza and giving her antibiotics, intravenous fluids, and an escalating flow of oxygen for her alarmingly low blood pressure and oxygen readings, said Dr. Christiane Corriveau, the critical care physician who treated Chloe once she arrived by ambulance at Children's National Medical Center in Washington, D.C., in the wee hours of Sunday morning. "I think everybody was concerned that this was more than just pneumonia — that her body was being taken over by the infection," she said.
Despite the aggressive treatment, Chloe was already entering the final and most life-threatening stage of sepsis, called septic shock.
Miller distinctly recalls how unresponsive his daughter was in the intensive care unit, not flinching when she got a shot or an intravenous line. Also, that her breathing was unnervingly fast: "In and out and in and out and in and out."
After getting blood and platelet transfusions, antibiotics, fluids, and heart medications, among other treatments, Chloe was improving by Monday, Corriveau said. By Tuesday, her breathing had eased and her "blood pressures were beautiful."
Miller, who works at Children's National in a fundraising role, recalls lots of updates as clinicians combated his daughter's low blood pressure and other symptoms. But it wasn't until the worst of the crisis had eased that he first heard the word "sepsis" and learned what that diagnosis meant.
"When they said, ‘She's out of the woods,' it really hit me just how life-threatening this was," he said.
Sepsis, sometimes called blood poisoning, describes the body's massive inflammatory response to an infection that infiltrates the blood stream. The body marshals all its efforts to protect the heart, lungs, and other vital organs, said Dr. Charles Macias, an emergency physician at Texas Children's Hospital in Houston and one of the collaboration's co-chairs.
A child's heart rate typically increases, in order to pump more blood to boost oxygen levels to organs and other tissues, Macias said. The increased demand for oxygen speeds up his breathing. Blood pressure can drop, as some vessels may leak and others may dilate.
In 2012, a 12-year-old New York student named Rory Staunton developed sepsis and died several days after cutting his arm while playing basketball, heightening national attention to the issue. A few states, including New York, have since enacted protocols mandating that hospitals regularly screen patients for sepsis. The Illinois version is dubbed Gabby's Law, after a young girl who died from sepsis following a tick bite.
Some screening steps can be quite simple.
At Cook Children's, a nurse will press down firmly on the child's skin, for three seconds, said Stephanie Lavin, the hospital's nurse quality leader for the sepsis initiative. The skin naturally turns lighter. But it should return to a normal shade within three seconds of releasing that pressure, she said. Any signs of poor blood flow — the jargon is capillary refill — indicates that the child is dehydrated or that blood has begun to shift away from the skin's surface.
That skin check is part of Cook Children's 18-point sepsis screening, a process that doesn't take much longer than a minute and includes asking parents if their child has shown any signs of confusion. The screening is performed with any emergency room patient who complains of a fever or another symptom that could signal an underlying infection, such as abdominal pain.
Any child who scores 5 or higher on the 18-point scale gets oxygen, antibiotics, and intravenous fluids — even before the blood test results come back, according to Lavin. That turns out to be a lot of patients: About 150 to 190 a month in the ER are identified by that initial screen as potentially having sepsis.
Regular screening already is routine in some other departments, such as the surgery and cancer units. Beginning this spring, it will be expanded to nearly every unit of the hospital, Lavin said.
Some of the collaboration's participants, including Cook Children's, have already had been participating in smaller initiatives against sepsis. Other hospitals can join the national effort; the next deadline to sign up is June 30.
Rory's mother, Orlaith Staunton, applauds the collaboration's efforts. But she still advocates for a more standardized regulatory approach: She wants to require every hospital in the U.S. to adhere to certain screening and treatment procedures.
Imagine, she said, that you're driving down the road with an ill family member in the car. "This hospital happens to be very good at enforcing their own sepsis protocols. This one is not so good. I end up driving into the wrong hospital. Worst-case scenario, my child or my loved one dies," said Staunton, who cofounded the Rory Staunton Foundation with her husband.
But Knight believes that the national collaborative model will work best, because it lets medical experts learn from one another. At Cook Children's, for instance, doctors and nurses continue to tweak their screening system, in order to most rapidly flag that "warm sepsis" patient.
"Will we bring kids into the hospital and watch them overnight who don't have sepsis?" asked Sanders, the chief quality officer. "Probably. But I'd rather do that to 90 kids and catch the 10 kids who are in early sepsis, and save their lives."
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