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R-Baby Introductory Presentation
1. An Evidence - Based Guideline EVALUATION AND MANAGEMENT of FEVER IN INFANTS
2. The following presentation is part of an educational program for physicians produced by the Division of Pediatric Emergency Medicine of the Morgan-Stanley Children’s Hospital of Columbia University Medical Center. Supported by a grant from the r-baby Foundation.
3. EPIDEMIOLOGY OF SEVERE SEPSIS IN CHILDREN IN THE U.S. > 42,000 Cases 50% < 1 Year Old 50% No PMH 10% Mortality
4. Reducing Infant Mortality From Sepsis ED Prevention Strategy: Bacteremia : The presence of bacteria in the blood of a well-appearing infant Complications of Bacteremia: Serious Bacterial Infections (SBI) Sepsis DIC Shock / Multiple organ failure Death Serious focal infections Bacteremia SBI ✖
6. Evidence Based Guideline Fever In Infants GOALS Primary : Identify infants at risk for Bacteremia/SBI Secondary : Standardized, Evidence-Based Practice Reduce Unnecessary Testing Decreased ED LOS
8. GROUP I (0-28 Days) High Prevalence of SBI/Sepsis (5-17%) Immunocompromised Can’t Limit Infections Appearance and Exam Unreliable Group Age Fever Cutoff Evaluation Disposition I 0-28 Days ≥ 100.4 Full Sepsis Workup (Include LP) Admit
9. GROUP II (29-60 Days) LOW RISK CRITERIA History: Previously healthy Normal behavior and feeding Reliable caretaker / phone access Exam: Well appearing Normal vitals & exam Labs: Blood: WBC ≥ 5,000 and < 15,000 B:N < 0.2 Urine: < 10 WBC/HPF CSF: < 8 WBC/HPF Group Age Cutoff Fever Cutoff Evaluation Disposition II 29-60 Days ≥ 100.4 Full Sepsis Workup Admit Vs. Discharge
10. SUMMARY: GROUPS I AND II Group Age Fever Cutoff Evaluation Disposition I 0-28 Days ≥ 100.4 Full Sepsis Workup (Include LP) Admit II 29-60 Days ≥ 100.4 Full Sepsis Workup Admit Vs. Discharge
11. GROUP III (61-90 Days) 61-90 Days Baby In Transition from Immunodeficient to Immunocompetent Fever Cutoff 100.4 Admit for Focal Infections (LIKE YOUNGER INFANTS) No L-P Unless Clinically Indicated Patients Can Be Discharged (LIKE OLDER INFANTS) Group Age Cutoff Fever Cutoff Evaluation Disposition III 61-90 Days ≥ 100.4 Bacteremia Workup (Blood and Urine) Admit Focal Infection Discharge All Other Patients
12. SUMMARY: GROUPS I, II AND III II 29-60 Days ≥ 100.4 Full Sepsis Workup Admit Vs. Discharge Group Age Fever Cutoff Evaluation Disposition I 0-28 Days ≥ 100.4 Full Sepsis Workup (Include LP) Admit III 61-90 Days ≥ 100.4 Bacteremia Workup (Blood and Urine) Admit Focal Infection Discharge All Other Patients
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14. GROUP IV: 3-6 Months History: BOTH height and duration of fever Group Age Cutoff Fever Cutoff Evaluation Disposition IV 3-6 Months ≥ 102.2 Bacteremia Workup (Blood and Urine Only) Discharge Fever < 102.2 Lasting ≥ 4 Days Urine Only
15. GROUP V: ≥ 6 Months Blood Testing Temp ≥ 105 OR ≥ 102.2 for 4 days Urine Testing Only if at risk for UTI or any fever x4 days Group Age Cutoff Fever Cutoff Evaluation Disposition V ≥ 6 Months + Immunized + Good Flu ≥ 105 Blood – All Urine – If Indicated Discharge ≥ 102.2 for 4 Days Fever ≤ 102.2 For 4 Days Urine Only: If Indicated Patients at Risk for UTI Circumcised < 6 Months Uncircumcised < 1 Year Old Girls < 2 Years Old Previous H/O UTI
16. Group Age Fever Cutoff Evaluation Disposition I 0-28 Days ≥ 100.4 Full Sepsis Workup (Include LP) Admit II 29-60 Days ≥ 100.4 Full Sepsis Workup Admit Vs. Discharge III 61-90 Days ≥ 100.4 Bacteremia Workup (Blood and Urine) Admit Focal Infection Discharge All Other Patients IV 3-6 Months ≥ 102.2 Bacteremia Workup (Blood and Urine Only) Discharge Fever < 102.2 Lasting ≥ 4 Says Urine Only V ≥ 6 Months + Immunized + Good Flu ≥ 105 Blood – All Urine – If Indicated Discharge ≥ 102.2 for 4 Days Fever ≤ 102.2 For 4 Days Urine Only: If Indicated
Editor's Notes
Smaller and lighter Bolder bigger Audio 1 Opposites
Credits slide Audio 1
Epi across top BIGGER Audio 2
Audio 3 Occult bacteremia: definition Complications: SBI List complications Last 5 seconds use the motion
Decreasing wellness of appearance Increasing height of fever bottom Bottom: all febrile children presenting to ED Change diagram Audio 4 under clinical : All febrile infants presenting to the ED (cap) No temp wbc Increasing fever Decreasing well appearance Arrow on bottom
Audio 5
Audio 6 Sarah’s portion
Smaller Audio 7 Baby on bottom-middle Say it = flash it High prevalence of Sepsis/SBI; 5-17% Flash in immunocomprimised Cant limit infections Apperance and exam unreliable
Audio 8 Low risk criteria included Moving baby with infection but not too sick
Summary page Audio 9 Summary: groups 1 and 2 On top of each other And low risk criteria
Audio 10
Summary of group 1 2 3 Audio 11 SUMMARY 3 groups on top
Audio 12 Introduction to guidelines for older infants 1)Moving baby no infection Bullet: community acquired pathogens: Sarah motion More flash in
Audio 13 At 1:25 Height of fever and duration of fever AS SAID
Audio 14 Patients at risk for UTI: Circumcised less than 6 mo Uncircum less than 1 yo Girls less than 2 yo Previous h/o UTI
All 5 groups Audio 15 Evidence Based Guideline for fever in infants