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Identifying Sepsis in the General Pediatric Setting · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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Also, is sepsis something that could happen, like some of the survivors of the
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flooding, the horrible?
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No. No, okay. No, I don't know if you saw the announcement. We didn't get anybody from those areas.
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Yeah, so, I mean, drowning, you know, we just had a drowning episode,
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you know, did that episode.
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But, yeah, no one, yeah, it was so quick.
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Not a lot of survivors, it sounds like. Yeah, if they survived,
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they were able to find a tree to hang on to.
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Or get into high ground, but everyone just got swept away.
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I don't know. I haven't read all the ME reports yet, but I suspect it's either
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just overwhelming drowning and just being crushed.
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Yeah. Oh, it's so terrible. Yeah, it's like a terrible way to pass away.
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Yeah, it's just unbelievably awful. Yeah, right.
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No, I mean, if it is, it's like being in the hospital for long periods of time
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and getting septic that way.
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I'm Holly Wehment and this is Pediatrics Now, cases, updates,
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and discussions for the busy pediatric practitioner.
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Click on the link in this podcast for free credit that may include CME,
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MOC, or ethics credit, depending on our topic or podcast.
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Pediatrics Now is brought to you by the Department of Pediatrics at UT Health
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San Antonio and University Health's New Women's and Children's Hospital.
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Today, back on the show is Dr. Ted Wu.
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He works with our pediatric critical care team.
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He's been in this field for 19 years and works in our PICU.
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Dr. Wu, thank you so much for being back here on the show and in the podcast studio.
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Yeah, thanks for having me. Last week, we covered the tough topic of drowning,
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and today we're talking about new research in sepsis and sepsis in general.
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And there's new research that could make treatment of sepsis more tailored.
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Yeah, just kind of wanted to define a little bit about, you know, sepsis.
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And we all know that it's kind of this huge immune response that we see to infection
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leading to organ dysfunction.
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And, you know, these are the type of patients we usually see in the ICU.
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It's challenging for our pediatricians because it happens most worrisome to
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our little ones, our neonates and infants, right?
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And they actually are the toughest ones to diagnose. So some of this research
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really uses genetic markers to categorize our patients with sepsis.
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So these would be all patients that we know have a clinical presentation of
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sepsis and that there are genetic markers that we could categorize them.
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The type of technique that they use is acronym is called JEDI.
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And it's able to categorize patients to very, you know, few categories,
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usually three or four categories, and that we were able to see whether or not each category can be,
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have the management tailored for them and kind of have some characteristics of that.
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So it's really at the infancy of this test to kind of see how it's at.
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You know, this is all coming, work coming out from Cincinnati Children's,
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you know, so more to come, definitely.
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But bottom line, depending on what that patient needs, that sepsis treatment may change.
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Correct. Correct. Right now, we treat sepsis very similarly.
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It's very much early recognition is really key.
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And being aware, hyper aware about that can really start even in the pediatrician's
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office or in the urgent care or in the emergency room, right?
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Just having that kind of keen attentiveness and being aware and ready to start
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interventions can make a difference, a way bigger amount of difference.
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And Ted, so a lot of times it's a patient who has the early signs of sepsis
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may be going to see his or her pediatrician.
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So it's really crucial and great for our listeners today to hear about what
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what are those warning signs, a refresher?
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What what should we be looking out for? Because, of course, you don't want to
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alarm a family, but not miss even that one patient, of course. Yeah.
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It's challenging, you know, as a general pediatrician, because how many children
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do they see that have come in with fever and, you know, kind of your upper respiratory
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infection symptoms? Right.
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And a lot of times. Yeah, exactly. A lot of times, especially during cold season
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and there are, you know, most of the time it's caused by viruses. Right. So what.
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What out of all of that makes you more aware that maybe we need to look in a
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little bit more deeply, right?
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And we should definitely be in more tune, definitely for our neonates and infants, right?
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So not only fever, it's poor eating, just lethargy, right?
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Just something is off. And using our caregivers or parents as also a guide that
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they actually would say, you know, there's something off about my baby,
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you know, and that might clue you in.
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And maybe we should do more of a workup for those types of patients.
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Should it be after, because as you said, those sound like common symptoms.
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It sounds like it could be the flu. It could be a respiratory virus.
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Should it be if it's continuing after a certain number of days?
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Or really, would that, you know, be the huge red flag if the caregiver is like something's not right?
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Yeah. And I guess, you know, it definitely varies with the younger patients of neonates.
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Definitely, like if they're not eating, you know, even in half of a day,
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that warrants some interventions at that time, either needing for fluids or
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IV fluids or, you know, some kind of hydration for those babies.
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Of course, older children can probably tolerate a longer period of time observing
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them for three or four days. But after five days, usually they're still having
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fevers and all those symptoms.
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All those probably should go to the emergency room and, you know,
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deserve a workup for blood work.
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And depending on what other symptoms they have, more imaging if necessary or
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other diagnostics as well.
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So if a child has had a fever for more than five days, say go to the emergency room?
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Definitely, you know, having communications with your pediatrician,
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right, or your parents, you know, it's a good practice to, you know,
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communicate with them on a daily basis.
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Just, you know, when they're ill like that. And if there's no change,
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yeah, it's kind of directing them to the emergency room is probably the next step.
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Because if the, or if the child still has a fever, but it's getting less or
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the symptoms are improving, then the fever is lower.
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Correct. Less needing to go to the hospital, right?
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It's that when the fever persists, patient's not really eating too great.
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Definitely signs of altered mental status, just not, or just being more somnolent
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and harder to arouse or wake up.
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Definitely need more incentive to go into the emergency room as well.
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Do we know why it causes loss of appetite?
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Is it just feeling terrible? That's a great question. You know,
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I think my theory has always been your body is using all its energy to fight
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an infection, right? So it's actually using actually a lot of energy.
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So all that blood flow is to your immune system organs, things like your spleen
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and your lymph nodes and your heart and lungs just kind of consuming that energy.
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So once you have no blood flow to your gut, because your gut,
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you know, usually uses a lot of blood or blood flow to absorb all the things that you eat.
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It just doesn't go as much blood there.
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So you're not going to eat, you know, in the hospital when we're treating for sepsis, we'll see this.
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You know, we actually don't feed when they're when they're acutely septic,
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you know, Even though we're always worried about the gut flora having bacteria
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that could translocate into the bloodstream and even make things even worse, right?
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So sometimes we feed very gently, very small amounts just to keep that bacteria at bay.
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But yeah, that's probably the biggest thing is that you're using energy and
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no blood flow is in the gut and you just don't feel like eating, you know?
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And your gut really just slows down. So that's why babies and toddlers,
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they tend to just throw up because whatever, you know, you try to,
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they feel hungry, but then it just doesn't move and they'll just kind of vomit any kind of stimulus,
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you know, so that happens.
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And the fever is our body doing its most important work, trying to fight that
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infection. Yeah, exactly.
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So that's, you know, elevating the body's core temperatures is one way to kind of kill bacteria.
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Actually, there's a lot of cascades that starts off and actually optimizes the
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immune system so that it works better in those environments.
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Yeah. So there's a lot of protective things for fevers.
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It's not that fevers are bad. And in this case, it's just kind of indicative
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that the body's fighting off an infection.
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At that point you just need to support the body right you're just going to lose a lot more,
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fluids through just the heat alone right off your skin so you just need to constantly
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be hydrating them so sometimes because they're throwing up they don't want to
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or they don't want to drink or eat anymore we have to give it through their
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intravenously at that point,
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Ted, does sepsis sometimes get better on its own or does it always require medical
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intervention or do we know?
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It always requires fluids.
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Whether you give it through the gut or through the IV, it always will require
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some kind of hydration to get through it, you know.
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So in this day and age, antibiotics is also will save people's lives because of that.
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You know, when you look at countries that don't have access,
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health care access, and they don't have access to fluids and antibiotics.
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Patients die or kids will die at home.
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Yeah. So when they get septic. Yeah. So and usually, you know,
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the common things are common versus viruses that are easily contractible. Right.
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And then it kind of builds up after that, meaning like you have a lot of congestion, a lot of.
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Those are the next symptoms. Yeah. the next in congestion and
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mucus uh and then you kind of it's a harboring
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for a lot of bacteria build up within your airways
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and then you're always just kind of have all this kind of gunk and then the
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bacteria that lives in your airways just kind of get lives and is able to grow
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and then kind of you get infected in your lungs so that's one of the things
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that can happen and then once it translocates into your blood because it's just
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an over amount of growth in or blood,
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then it can get, that's where it really cascades in this kind of inflammatory
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process, as we know as sepsis, right?
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So all the other things that we have, worry about lung infection,
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ear infections, all those that we can treat for antibiotics.
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And usually patients, they just feel terrible.
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But when that bacteria becomes overwhelming and spread through the bloodstream,
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that's when everything starts going into dysfunction, right?
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Your heart starts dysfunctioning and dysfunctions your kidneys as well.
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So, or your liver, you know, everything's gone on high, high,
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you know, reamed or high, you know, revved up, revved up because of the inflammatory
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process that it got started from the bacteria itself.
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And Ted, as a doctor on the front lines in the pediatric ICU,
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do you often see kids that are in the late stages of what you're talking about? Yeah.
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Yes. Actually, when they when they come to us, they're in their late stages.
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We call late stage sepsis when patients start developing hypotension or low
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blood pressure and they need vasopressors, which are medications that are continuously
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infused, things like epinephrine and norepinephrine or vasopressors.
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And they need to be constantly infused in order to maintain good blood pressure.
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If you don't have good blood pressure, you start shutting down your organs,
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things like your kidneys and your liver.
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Your body's really good with preserving blood flow to your heart and your brain.
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Those are the two things that it cares about.
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And if those things start shutting down like your heart and not able to perfuse
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your brain as well, then it starts really shutting down.
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And that's what we really worry about.
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So then it needs medications and other therapies, including ECMO,
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in order to kind of improve that perfusion.
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So yes, in ICU, we see the kind of late stages.
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Our inpatient pediatricians are the ones that deal with a lot of the early stages of sepsis, right?
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And it's usually, we don't think of it that way, but we always teach our trainees
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to always think about that because it's always the brachiolytic that becomes
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really dehydrated, right?
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And it becomes really tired and lethargic, right? And they just look listless.
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That's a kid in beginnings of what we call shock, right? The lack of perfusion.
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That can progress into sepsis, kind of a form of early concerns for sepsis, right?
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So usually they get fluids early on in the emergency room and get antibiotics
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and then a monitor in the inpatient, right?
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If they don't progress or don't improve, and if the blood pressure starts dropping
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along with having high heart rates, then they'll come to the ICU after that.
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And so some of what you'd say for a respiratory virus or the flu,
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getting fluids and rest, that could really be help, that does help in this case.
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Yeah, and that's really for, you know, our outpatient pediatricians,
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you know, just being astute about that, right?
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Some are, I know the practice might not be there as in giving IV fluids in the clinic, you know.
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But in urgent care, you might get IV fluids in the urgent care kind of setting
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in order to hydrate somebody.
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If the child seems dehydrated. Yep.
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Yep. Is there an easy test for that? Like to make sure for for sepsis or dehydration or dehydration?
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Not like an overwhelming test. You know, we always when we're teaching our residents,
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you have to account for the whole whole picture. Right.
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Things like dry mucous membranes, sunken fontanels for babies,
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you know, dry skin or turger, turger, skin turger. Right.
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Low urine output, even, you know, alter mental status. Those are all kind of signs for dehydration.
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There are tests. Sometimes we look at Buen and creatin, if you want to be kind of formal about it.
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Looking at a kind of blood chemistry and electrolytes, you can make that diagnosis.
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But usually you already have the story beforehand and in your own exam and looking
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at the patient and kind of knowing, okay, this patient's dehydrated. Yeah, so.
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Can sepsis be treated in the general?
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Pediatric setting, say with antibiotics and the fluid, you advise taking it,
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taking that patient should go to the ER.
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Yeah, they usually need to be observed. When we're talking about sepsis,
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it's already kind of all the signs of the fever and low blood pressure and high heart rate.
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You know, those things are already kind of set forth already.
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They, more importantly, they need to be admitted to the hospital to be observed as well, right?
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The challenge is sometimes when they go to the emergency room,
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given the interventions and they seem to be doing okay, right?
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It's whether or not they should be discharged or not, or just be observed overnight, right?
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Definitely the younger patients like our neonates and infants,
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they all stay overnight to be observed because they, one, it's hard to communicate to them, right?
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And really just being, and they are more susceptible to infections, right?
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So sometimes we have astute parents that just really know, you know,
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their child or just a really well read, right?
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So sometimes we'll let them go home, but we're really vigilant in following
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up with their pediatrician in those cases. Yeah.
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So. Is there one antibiotic that's the first line of therapy or does it just
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vary depending on the case?
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It's very broad, you know, it's more, it's more age, age dependent.
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And we kind of look at, you know, all our medical students know that usually
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in the younger age, like neonates and infants, we usually start with ampicillin
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and cefotaxime or gentamicin. So it's a very broad range.
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And then everyone else gets like ceftrioxone, you know, kind of very broad range things.
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Sometimes our children with chronic diseases or patients that have our oncology
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patients or transplant patients, those require some additional antibiotics,
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say like vancomycin that we worry about for more resistant type bacteria because
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those children were in the hospital.
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They were exposed to so many different things and antibiotics as well.
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So they've already kind of been exposed to some drug resistant bacteria.
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Can you explain to us what causes sepsis? What is happening in the body?
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Yeah, so it's usually bacterial and bacterial related.
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Sometimes we don't find the cause, like the actual cause, but they all present very similar.
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And where the body has this huge inflammatory response to the bacteria and causes
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what we call this process where it generates a lot of capillary leak where you
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have become really swollen.
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And a lot of your fluids just become linking into your interstitial fluids.
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So a patient can get really swollen that way.
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And it's in response also that your body's trying to fight this bacteria.
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This bacteria is kind of overgrown as well.
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So the antibiotics is one method to kill the bacteria, but then it doesn't kind
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of, so you're treating the cause, but you're still dealing with the inflammatory process, right?
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So some folks might say, hey, it's an inflammation. Can you give steroids for that?
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Because steroids used to be kind of this anti-inflammation.
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That's what we use a lot for, for a lot of different diseases.
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We don't do steroids just off the bat.
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Now we just really use it if the child has adrenal insufficiency or they have
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low cortisol levels, then we'll give steroids for that. Because it lowers the
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immune response, right?
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It lowers the immune response, but always the caveat is that sometimes that
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immune response is what's fighting the infection, right?
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So you don't want to tamper, you know, that response.
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You want that response. Yeah, you need it. Yeah, it's not, it's not,
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it's a very shotgun approach because you're basically shutting out all the immune
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system, right? So you're not, you're not tailoring it.
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So that's why we don't give steroids just to anybody. We just give steroids
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really for the patients that are not responding to vasopressors, you know.
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So that's usually when we start thinking, okay, they need to be stressed for that cell.
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Ted, is sepsis often missed in the general pediatric setting?
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Yeah, I mean, we always worry, you know, when, you know, I see it on a different end.
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I see it on the end of the patient that has seen sepsis.
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Different pediatricians or different urgent cares and kind of the same response
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is, my baby had a fever or my child had a fever, didn't go away.
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We tried antibiotics. It still kind of came back, never really gone away.
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Look, he's kind of getting worse.
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And, you know, parents get really frustrated in that situation, of course.
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But when we see that, we see it on the other end.
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Okay, they've kind of failed a lot of different therapies. Is there something
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else that's going on? But we would treat the sepsis and support the patient's
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body to kind of fight this infection is usually what we'll go through.
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You know, we work at a ICU that has to think about, you know,
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what made this patient susceptible.
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You know, those research topics that we were talking about earlier,
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we don't have access to those things.
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So we need to kind of think outside the box that maybe this patient was born
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with, We had to rule out any kind of congenital inborn errors of metabolism
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where this made this baby or patient susceptible to infection.
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So we always have to think about those diagnoses as well. So super rare.
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Yeah. But we see it in our ICU. You see what is super rare?
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These inborn errors of metabolism or congenital disease where they don't respond to infections well.
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Like they lack the response to infections. Right. Most children,
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they respond appropriately, you know, and, you know, even through sepsis,
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they're responding appropriately and they just need the support to get through.
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It's usually the babies or children that have congenital diseases like that,
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then we also have to think about, okay, like, why are they getting so sick just
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from a simple bacterial infection, you know?
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So, like, they're not responding how we usually see them respond.
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But if a child is otherwise healthy,
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it wouldn't be usual for a bacterial infection to turn into sepsis?
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Or is that how it starts? That's how it starts out.
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Always. Yeah. Any sort of bacterial infection? You have the potential to becoming
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septic. Wow. Yes. Yeah. Another thing to worry about as a parent.
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Yeah. I mean, that's why antibiotics kind of go so freely out there because
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that's what we, and that's what changed, you know, like antibiotics were made
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in the beginning of the 20th century and it changed everything.
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In the sense of made a huge impact that children didn't die from bacterial infections, you know? Yeah.
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So that and vaccines, right? Yes. Those made huge impacts.
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More than, you know, more than doctors, right?
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Oh, it was amazing. It's like a public health, you know, endeavor that just
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changed our world, right? Yes. Yeah. It's amazing.
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I know you recently went on a trip with the med students to Guatemala. Mm-hmm. And...
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We're there at the people can buy antibiotics, though, over the counter.
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So that creates its own problem.
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Right. Yeah. So they have access to things like linazolid, which is a very powerful antibiotic.
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It's a very good antibiotic as well.
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But with that, it kind of builds resistance. And we were our med students who
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were their project was educating the public or at least the clinics that we're
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going to about the dangers of antibiotic resistance in their community when they did that.
22:56
Right. Because, you know, you take antibiotics, it doesn't all get degraded.
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It goes into our sewer systems and it goes back, you know, to the water and
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goes back to our animals or cattle and stuff. and it just goes back right in the system.
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So it kind of, the bacterium kind of just feeds itself, right?
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So antibiotics, though life-saving, causes some other unintended consequences, right?
23:22
Yes. And we have an episode on antibiotic stewardship with Dr.
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J.B. Canty, pediatric infectious disease.
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He was the first doctor to be double-boarded in neonatology and infectious disease.
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Yeah, yeah. So that's in this news feed. but.
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What about, there was a pediatrician yesterday, she was telling me she's seeing
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a lot of hand, foot, and mouth disease.
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Like, could something like that that's very common turn into sepsis,
23:51
or I don't... It can, in the sense of, you know, usually when folks,
23:56
it still comes from a virus. Yes.
23:59
And it transgresses to some kind of bacterial infection, say,
24:04
usually like a skin infection, and then progressing into getting infected into
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the bloodstream. That would be kind of the extreme case of that, right?
24:12
So, or, yeah, some kind of nidus that causes more infection that leads to a bacterial infection.
24:20
Yeah, so. Do you want to mention anything about key updates in the latest surviving
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sepsis campaign guidelines?
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Yeah, I mean, these guidelines came out in 2020 and it's all about early recognition, right?
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And once you recognize that patient that you're concerned about,
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it's the first hour is so important, right, of interventions, right?
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And fluids is the big thing. giving fluids to the patient orally or IV, right?
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So if you're in the emergency room or urgent care, getting fluids to them is
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so critical that you actually will decrease mortality in that first hour.
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It's kind of a survival curve during that time.
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So it's challenging, right? Because IVs in children are not always easy to get,
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especially in small babies.
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So we've created other devices, one called the intraosseous needle,
25:16
which actually goes into the bone marrow in order to give IV fluids or IV drugs that way.
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So some people might feel that it's extreme, but it is, we sometimes,
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if we can't get anybody because get IV access because of dehydration.
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An IO is actually very important and vital.
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You will save someone's life using that gun.
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If done correctly, and most of us that take PALS or Pediatric Advanced Life
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Support, we learn that skill.
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It's whether or not we're proficient at it, right? So ER physicians all learn how to do it.
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They don't all learn how to, you know, practice as well because it's rare to
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do it in practice, right?
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But being astute enough to get
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an IV or use an IO to give fluids is really important in that first hour.
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And did you say is it like an actual gun that goes, like it's not a... It comes as a drill.
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It's actually a device that was developed here in San Antonio.
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Really? Yes. Here at the UT Health Science Center, actually, yes.
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And the creators are, you know, they've done well for themselves.
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I think I heard about this. They're very rich now, right?
26:26
Well, it's a device that's used internationally, and it's a drill.
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Because we used to have to use our hands to kind of just push this needle through.
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Now you use a drill. It's a drill specifically for this needle,
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and it makes it very quick and very easy if aimed correctly,
26:43
right? And you have to put it right, it goes right to the bone marrow?
26:46
Right to the bone marrow, right. Yeah.
26:48
So for children, it's usually in the distal femur and or the proximal tibial.
26:54
And then here in our health science, they did it in the humerus.
26:57
They also did it in the sternum for adults.
27:01
And they showed it didn't have pain. They actually have YouTube videos where
27:04
they showed it in adults and they did it live on them and it didn't hurt.
27:09
They didn't use any kind of local anesthetic or lidocaine for that.
27:14
Yeah, and they did fine with it. And they were able to give fluids and medications through it.
27:18
How is that possible? Wow, that's amazing. Because the bone marrow has a lot
27:22
of blood flow and blood capillaries through it.
27:25
So you're able to kind of disseminate blood, get things in the bloodstream pretty quickly that way.
27:30
So as an emergency technique, we use it all the time.
27:33
You know, EMS people will use it a lot as well.
27:36
So you've done a lot of those, I take it. We do it, yeah, on the other end when,
27:41
you know, usually our children, they, you know, we have a lot of skilled nursing
27:44
and physicians are good with IVs.
27:47
And if we can't get it, we're going to other places and use other techniques
27:51
to get, you know, get access.
27:55
We use that drill. We use that, use that for emergency. And then we use other
27:59
kind of devices to give medications more long term if we need it.
28:04
Yeah, it's a kind of a much more short term device used only for like 24, 48 hours like that.
28:10
And then usually our patients need something else. And you mentioned ECMO earlier.
28:15
That's basically where the machine can take over and breathe for the patient.
28:19
Is that correct? Yeah, so ECMO, yeah, ECMO, again, it's kind of a heart-lung bypass machine, right?
28:26
So if patients become, sepsis becomes so overwhelming that the heart can't pump
28:32
itself, the lungs are not working from ARDS, it can't get oxygen, it can't go blow off CO2.
28:38
So then what ECMO does, it doesn't treat the sepsis. It just helps support the
28:44
body while it's fighting this infection.
28:47
Give it oxygen, take out the CO2, and pump blood throughout the body.
28:51
That's what the ECMO machine is doing.
28:54
So that's revolutionary as it's all. ECMO got developed in neonates back in
29:00
the 70s, and that's where that technology is slowly kind of built up, built up.
29:04
And now what's phenomenal about the technology is that it's become a lot safer.
29:09
It used to be fraud with a lot of clotting and bleeding, And it was really difficult
29:14
getting these tubes or cannulas into patients.
29:17
All that's changed. And to be honest with you, it's because of adult COVID and
29:22
adult SARS, if you remember that pandemic that happened, it's because of that.
29:27
And that's where the industry really changed and made that available safer for patients in general.
29:33
And then we've been benefiting that for neonates and pediatric patients now.
29:37
Wow, that's so interesting and so amazing. Yeah. So many things go back to COVID, it seems like.
29:44
It's changed the world. I mean, it's kind of, in the sense, it's kind of like our moonshot, right?
29:49
In the sense that we designate a lot of resources in the research,
29:54
right, to develop a vaccine and then to put so much resources in the,
29:59
not only in the diagnostic, but the therapy.
30:01
You know, that was huge. So, yeah. That is huge.
30:05
Ted, how important is point-of-care lactate in initial evaluation,
30:10
and how should it guide therapy?
30:12
Yeah, that's also in the Surviving Sepsis Guidelines is checking lactate levels, right?
30:18
The unfortunate thing when that was published, we did have point-of-care lactates,
30:23
meaning like if you could get a finger stick blood and then send that off.
30:27
It looked like an acu-check, right, a glucose glucometer, and you can check the lactate level.
30:32
And lactate levels have been shown. That's the only way that we can tell if
30:39
a person is not getting enough oxygen to their major organs,
30:43
like their brain or kidneys, then that's a problem.
30:47
And we need to kind of optimize that.
30:49
Now, because that device is not available, the company that made it just,
30:55
it wasn't, it lost its FDA approval for the cartridges.
30:59
Oh, really? Specifically for it. Yeah. And this happened actually before COVID.
31:03
And then, but now every hospital has lactate levels readily available.
31:08
Like you can send it off pretty quickly and you'll get the results pretty quickly.
31:11
So that's very beneficial for ER medicine, folks.
31:15
So that leads us to this next question. I know we've covered some of this,
31:19
but bottom line, what is the most critical thing a general pediatrician can
31:23
do in the first 10 minutes of recognizing pediatric sepsis?
31:28
Yeah, once they're recognized is optimizing fluid and starting antibiotics.
31:32
I think that was the other thing in the surviving sepsis.
31:35
Those two things, initiating in the office while you're sending them off to
31:40
the ER or calling EMS to get them transferred to ER will save their life, you know.
31:46
So sometimes it's difficult to have those kind of emergency,
31:50
you know, kind of things in the office. I know it's challenging as well.
31:55
But giving antibiotics, you will also save their life.
31:58
Sometimes giving a shot like Rocephin early on is also beneficial,
32:02
you know, so in order to do so.
32:04
Any other antibiotics you want to mention or would that be the first one?
32:07
No, that's usually the first one, you know. There's probably,
32:10
that one is not usually recommended for, you know, babies less than six weeks of age.
32:17
So send the baby to the ER. Yep. Send the baby to the ER.
32:20
And then give that antibiotic to the older kids, a shot of it,
32:25
but still send the child to the ER. Yes.
32:27
Once it's recognized that the patient has sepsis. Yeah.
32:30
And a level one trauma center like University Hospital?
32:34
Usually a pediatric emergency room like at University Hospital.
32:37
Hospital, yes. Which a lot of people don't realize. They think that they...
32:41
Or know that it's a pediatric, we have pediatric ER doctors,
32:45
it's a pediatric ER. Right.
32:47
And the only level one trauma center in San Antonio other than BAMC,
32:52
right? Yep. The military hospital.
32:55
Do you want to walk us through an ideal first hour management scenario for pediatric sepsis?
33:01
Yeah. We, in the first hour, once they arrived at the hospital,
33:05
we definitely attempt to get some sort of IV access or IO access for them. and administer fluids.
33:13
All our trainees know giving 20 cc's per kilo of some kind of isotonic fluid,
33:20
which is usually normal saline or plasmalite or lactated ringers in the first hours is critical.
33:27
So, and then more importantly is not walking away, but reassessing after that
33:32
first bolus, right, of fluids,
33:34
kind of watching their vitals, see if there's changes in their heart rate,
33:39
Any changes in their blood pressures or in their altermental status, right?
33:43
Or even urine output and capillary refill.
33:46
That's kind of the clinical exams that we use to assess and reassess how patients
33:53
are responding to the therapy.
33:56
That's what we teach our residents and fellows right to
33:59
once you do something go ahead and reassess right away
34:02
because the clinical exam is the one things that you'll get
34:05
response like you'll see the results right there at bedside
34:08
faster than any test than you do right so and i always joke or not joke but
34:13
in the icu we're always a hypothesis driven physiology lab so meaning like if
34:20
you think it's this try this and you want to see the response and then kind
34:24
of be ready when it doesn't respond what you think it will do, right?
34:29
So usually they're giving fluids and then if it doesn't respond or still kind
34:34
of persists, we usually give another 20 cc per kilo bolus.
34:38
And after that, if that is not a response in that first hour,
34:42
usually we start thinking, okay, maybe this patient needs to start on some what
34:45
we call vasopressor drips, which is epinephrine or norepinephrine.
34:50
They can always be started into a peripheral IV.
34:53
Ordinarily, they should be starting into what we call a central catheter,
34:57
which goes directly into a main vessel of the body.
35:01
But that needs to be placed by, you know, someone who has experience with placing
35:04
those catheters, either an emergency room doc or ICU doc.
35:08
So usually we do that, try to get that at least established within the first hour.
35:13
So that seems like a little bit, like three things, but an hour goes by really fast, you know.
35:20
I bet. Yeah, because in that you need to find a nurse that's or a physician
35:24
that's skilled enough to place an IV into the patient.
35:27
And then you're also drawing labs at that time, right?
35:30
You're getting a CBC, a chemistry and lactate level or COAG levels as well to
35:36
kind of assess the patient and see how severely sick they are and where they're at.
35:42
Ted, is there one message you want every pediatrician who's listening to take
35:47
away from this episode about sepsis? I know we've covered a lot here.
35:51
Yeah, I mean, you know, those are trainees that go into general pediatrics.
35:56
I go, never underestimate like your ability to sense if this baby or child doesn't look right.
36:02
And or if you get the history from the parents that doesn't look right,
36:05
it's OK to kind of do the workup, start the workup or even start antibiotics at that time.
36:11
I mean, if you're suspicious that this patient is moving towards being septic,
36:16
right? So is that hesitancy?
36:18
And really, our pediatricians kind of, this is one of the things that keep them
36:22
up at night, is that did they send home that kid that was sick and would get
36:27
worse and go to the emergency room? You just feel terrible.
36:30
I mean, you kind of advise parents about that, right?
36:32
So being vigilant when you're kind of, your senses are going off when a child
36:37
is sick like that. Mm-hmm.
36:39
And no pediatrician, of course, wants to send a family or child to the ER unnecessarily.
36:44
So there's that stress and pressure there.
36:47
Yeah, it's kind of that balance, right? Where do you find, you know, it's true.
36:52
A lot of the things that we see in the general pediatrician's office are easily
36:56
treated and reassured parents to go home, make sure that they're well rested, get fluids.
37:01
But yeah, what makes a difference? And sometimes it's time that you need time
37:06
to kind of let it get this disease kind of sorted out.
37:09
But after that, it's really being communicative with the families, right?
37:14
But if your spidey senses are going off, just go ahead and send them to,
37:17
you know, the pediatric emergency room.
37:20
And have someone or call the family the next day or have someone from your clinic.
37:24
Clinic follow up. Yeah, exactly. I'll see you back in a couple days.
37:27
Yeah, that's a good process and good practice to do, you know. Yeah.
37:31
So some practices allow that easier, right? or built that in that some kind
37:35
of assistant follows up, right?
37:37
So some smaller practice, they do the actual calling, you know?
37:41
So, but it's just being that vigilance, you know, is always there or suspicious.
37:46
It's always in the back of our minds, right?
37:49
Are there blood tests that can be done in the general pediatric setting?
37:53
Or is it, I know you said, send the child to the ER for the blood workup or sepsis.
37:58
Yeah, no. That's what you reckon? Yeah, they used to try to advocate for some of the things,
38:03
but end up now doing blood work in the pediatrician's office is hampered with
38:09
a lot more regulations because you have to validate that the staff is trained to do all those tests.
38:17
And so, yeah, a lot of pediatrician's office are not going to take that liability
38:21
or that amount of work to sustain that.
38:23
So urgent carers might do that or some urgent carers are next to a lab.
38:27
They might be able to do that.
38:30
And we have, the doctor I mentioned earlier, Dr.
38:34
J.B. Canty, is working on a project with the NIH where we have a phone number
38:39
that I'll put in the text for this podcast.
38:41
So for baby patients, if listeners are wondering, does this baby need antibiotics,
38:46
you could call or text this number and get right through to ask him about that.
38:52
So I will put that in. Yeah, I mean, that's the dilemma that a lot of ER docs kind of have, right?
38:58
They get it they get it's always the age
39:00
group they'll get like a two-month-old because it's right outside
39:03
this one who's febrile but looks okay how
39:07
much of a workup do i need to do on these on these
39:10
children right so it's the spinal tap blood draws and urine right those are
39:15
the three things that we check so that's what this project is really kind of
39:19
geared for is for those practitioners that kind of encounter that yeah well
39:24
ted this has been so fascinating and it's such an honor to talk to you here
39:29
in the podcast studio today.
39:30
Is there anything else you want to mention before we wrap up to the pediatrician listener?
39:35
No, I think we said it before as in how much, you know, a gender pediatrician
39:40
kind of is able to see and they offer a lot of reassurance for our parents and
39:44
guiding a lot of uncertainty.
39:47
And yeah, just being vigilant about being those kids that you're really uncertain about.
39:52
And maybe say to the parent, I just want to make sure if you're doubting it, but let's rule this out.
39:58
At least go to the ER, have this checked out. Right, right.
40:01
Yeah. Having that discussion, you know, with your families, you kind of have
40:05
to gauge, you know, how much some families are willing to kind of go through
40:10
to kind of have that reassurance or that peace of mind, right,
40:14
to go through those tests.
40:15
That is also a tough discussion to have sometimes. Yeah. So.
40:19
Because when the child gets to you, it's a lot harder to treat.
40:24
Yeah, it's a lot harder to treat, especially if we're already behind.
40:27
Yeah, so we're kind of playing catch up, you know, especially from a fluid standpoint.
40:30
Sometimes patients can become really dehydrated from sepsis.
40:34
They just don't want to drink and they're staying out. They don't want to drink
40:37
or they didn't get enough fluid when they're resuscitating at whatever facility
40:40
they were at prior to coming to our unit. Yeah, so that happens.
40:45
When it's missed too, do you see it a lot where the parent didn't bring the
40:49
child to see the pediatrician or does it just vary?
40:51
It varies. Yeah. Either way, the families are extremely guilt,
40:54
feel the amount of guilt, you know.
40:57
So tough. Yeah. And you kind of have to also reassure them that,
41:01
you know, you did the best that you knew.
41:03
And it's really, those are the things that are really hard to predict, you know.
41:07
So, but yeah, we just help our families kind of navigate through that as well.
41:12
Well, in this high-stress, high-burnout career and all of the difficult things
41:18
you do on a daily basis in the PICU, I like to talk about having a life outside of medicine.
41:23
And you went to UCLA, and so you've worked on films, I hear.
41:30
Yeah, yeah. I mean, it was in Hollywood, right?
41:33
So they offered extra work, being on extra on movies or film.
41:39
Yeah, so I was able to, you know, being a college student and even just being
41:44
paid by food was a treat, right?
41:48
So, yeah, I was able to work on this old cartoon show or this old kid show,
41:52
Mighty Morphin Power Rangers. I'm being an expert on that.
41:56
Yeah, so that was fun. It was really tedious work, though.
42:01
So were you one of the Power Rangers? I was not with the Power Ranger.
42:04
Actually, because I'm a stocky guy, short, stocky guy, they got me to wear one
42:10
of the costumes of the villains because they were these big costumed heads.
42:15
And I basically wore it on my shoulder and then wore this thing and just kind of acted it out.
42:21
So, yeah, I got paid a whole extra meal.
42:24
All right. Which helps when you're an undergrad. Yeah, when you're an undergrad. Exactly. Exactly.
42:30
So, yeah. So that's kind of some fun facts.
42:33
Wow. In my career of odd jobs that I've had, yeah.
42:37
The Power Rangers. Yeah. And then did that help form a love of film for you?
42:44
Or you realize like how tough it is to make a film? Oh, yeah.
42:47
You know what? You know, I don't know if it's being in California or L.A.
42:51
But yeah, no, I've always enjoyed films and been a film geek myself.
42:56
So you're from California. I'm from, yeah, from Los Angeles.
43:00
Yeah. So I don't know, having family in film, maybe that had something to do
43:04
with it. But I really enjoyed the art of it.
43:08
You know, I both enjoyed the popularity of things, but also kind of all the artsy stuff.
43:13
So just really enjoy that kind of medium, you know, but knew how hard it was,
43:19
you know, and in order to kind of pursue that and the amount of creativity and that it takes.
43:25
So I was like, oh, man, I don't I don't know if I'm wanting to put myself through
43:29
that much uncertainty, you know, so.
43:33
But yeah, no, I think it's a it's a it's a very interesting field. That's for sure.
43:37
So and you have a relative who was in some films.
43:41
Yeah, yeah. He was an actor. He's an actor as well. He's in a Mortal Kombat.
43:46
His name is Robin Shue. So now is a, now people do recognize him because I thank
43:51
God for, for streaming and Netflix and, and that movie being on,
43:54
on, on constant stream, but it's based on an old arcade game from the nineties, you know,
43:59
so that's always constantly being remade.
44:02
So, but yeah, he's, he's enjoyed that kind of celebrity life or,
44:07
you know, where he's going to comic cons and, and then signing the autographs.
44:11
So I'm sure he enjoys that kind of.
44:14
That life yeah so for our san antonio listeners he
44:17
is coming to comic-con this year in october
44:20
yeah that's right to sign autographs make an
44:23
appearance that's right that's right ted as a film buff
44:26
is there any any film that's on your mind or one that you recommend or do you
44:30
have it's hard to i think it's hard to choose a favorite film when you really
44:33
like from uh oh as a oh you my favorite film yeah my favorite film still is
44:39
it's a wonderful life that's a great one yeah so So I really enjoy,
44:45
it was an old way of movie making.
44:49
Frank Capra just captures a lot of Americana in it, which is really fun to watch.
44:56
Yeah, so you don't see those things. And there's so many subtleties in that
44:59
movie of how the, about appreciating the little things in life, right?
45:04
So it's led me to appreciate a lot more about it.
45:08
The other one that's always on my mind. Do you bring that to your family,
45:12
your two kids, your wife? Yeah, yeah.
45:14
I mean, sometimes I'll talk about it, you know, but maybe not in my daily life.
45:20
It's hard to do that in a daily life. Yeah, exactly. The other one that's hit
45:23
me, I always think about a lot, and maybe because I'm more of a father, it's Interstellar,
45:29
a Christopher Nolan movie that just kind of, I know it's about space and sci-fi,
45:33
but it was really about like generational impacts, you know,
45:37
and how we're viewed by our children.
45:40
You know and I thought that was just like such well made in that bringing that
45:45
sense you know in you know so that'd be a good one to watch I have not seen
45:49
Interstellar oh you haven't seen Interstellar is it for adults or adults and kids or.
45:54
Kids might find it maybe a little bit boring. I haven't shown it to my kids
45:59
yet, even though they would like the sci-fi aspects, because there's some time traveling going on.
46:04
But not in the, it's like hardcore time travel, like, you know,
46:08
so with black holes and stuff.
46:10
But yeah, it's a good watch, though. I want to see that. Any other films you
46:14
want to mention that you like?
46:15
Film review. No, no. I mean, those are the two that, you know, I've been thinking.
46:20
TV shows, I think, recently, like, of medical-related is The Pit.
46:25
I've heard good things about that. Yeah, I've heard good things about it, too.
46:28
I've watched maybe one episode.
46:30
And, you know, it just brings back the show ER, I remember, back in the day.
46:35
And that had a lot of impact on me. I didn't know how much it did,
46:39
but it really did, I guess.
46:40
I remember watching it, too. Yeah. But I did, like, there was a really old show called Emergency.
46:45
Emergency it was just about paramedics and it
46:48
was made in the 60s i believe yeah i remember
46:51
watching that i really like watching people going
46:54
to you know helping out in emergencies maybe that that has
46:57
more impact for me going into medicine you know
47:00
kind of being that person that's available to help
47:03
in emergency that to me it was like really intriguing for
47:06
for so many different reasons you know just kind
47:08
of being on the spot and being able to react in emergency
47:12
situations yeah so that helped inspire you
47:14
to do what you're doing today yeah definitely yeah so i
47:18
know that's a little bit a little bit weird you know yeah but
47:21
no i i always knew i was growing up
47:24
i was a kind of an anxious kid that never really showed it
47:27
or nervous but definitely as
47:30
i gradually grew into the
47:33
career i found myself really calm during really
47:37
stressful situations so i felt
47:39
that was okay i can i can do these and i enjoyed it
47:42
i kind of gravitated to those moments you know
47:45
um so and really able to think clearly through
47:48
those moments so i thought that try to find places i could use that to you know
47:53
to my benefit or or you know anyone's benefit bring so in those moments so well
47:58
that's great where you're thinking quickly and you're not panicking and you're
48:04
able to just stay focused Yeah, yeah, yeah.
48:07
Like Superman. That's the other big movie coming out. I mean,
48:10
I think you guys are getting a movie plug.
48:14
My kids keep talking about it. Like they want to see that as soon as possible.
48:18
Yeah, it's like the seventh reboot or something. It's supposed to be a good one. I don't know.
48:22
Like, I don't know. Yeah. I think you guys are superheroes, what you do on a
48:27
daily basis. It's just incredible. Well, thank you. Thank you.
48:29
And our pediatrician listeners, of course.
48:33
Ted, thank you so much for being here in the podcast studio again on Pediatrics Now.
48:39
Music.