Case 32 A feverish girl with poor feeding
A 10-month-old female infant, Elena, is brought to the ED with a history of fever for 1 day, measured at 39°C. She has been unwell with poor feeding, but with no symptoms of any specific disease. At triage Elena is afebrile (36°C), with a heart rate of 185/min, CRT of < 2 seconds centrally and peripherally, respiratory rate of 30/min and SaO2 of 99% in air.
She is seen directly by the paediatric ST2. Her observations remain unchanged and the ST2 can find no focus for any infection. Elena remains afebrile.
The ST2 discusses Elena with the paediatric registrar. They decide to admit the child to the ward for observation and to carry out a partial septic screen; blood tests (including CRP and blood cultures), a CXR and a clean catch urine sample. The blood tests and CXR are performed before Elena leaves the ED. An attempt is made at iv access but fails and a decision is taken not to make a second attempt. Elena is transferred to the ward where she is placed in a side room, and her mother is asked to collect a urine sample.
Is this a reasonable course of action?
The night team arrive and Elena is handed over as being generally well with a history of reported fever, but no signs on examination. The CXR is reviewed and is normal. The blood tests are still awaited.
At nursing handover it is reported that a urine sample hasn’t been collected and a decision is taken to try again in the morning. The nurses have no plan from the doctors as to the frequency of observations and a plan is made for routine 4 hourly observations.
Is this an appropriate course of action?
At midnight, Elena is found to be cold with a temperature of 35.5°C, heart rate 190/min and cool feet. The window to the room is open and the low temperature is thought to be environmental. The window is closed and a blanket is placed on her. The doctors are not contacted.
At 04.00, Elena is still cold and the temperature is unchanged at 35.5°C, despite the earlier measures. The night ST2, Dr Edmunds, is contacted. He is in ED with a combative alcohol-intoxicated teenager and does not feel he can leave. He reviews Elena’s blood results and is reassured by a CRP of 8 mg/L (normal<6 mg/L) and a total WCC of 3.0 × 109/L (4.5–15 × 109/L). He advises the nursing staff that he will come and review her as soon as he is able, but that she is unlikely to have a significant illness. He asks the nursing staff to call the night time registrar, Dr Stark.
Dr Stark is called but is busy on the neonatal unit and also advises the nursing staff that she will review the child as soon as she is able to.
Is this a reasonable course of action?
At 05.00, Dr Edmunds reviews Elena. He finds that her temperature is now only 35.0°C, she is cold to the knees and elbows with a peripheral CRT of 5 seconds and a heart rate of 210/min. The respiratory rate is now 40/min, but the SaO2 remains 99% in air.
Dr Edmunds, fast bleeps the registrar and then tries to gain iv access. When Dr Stark arrives she inserts an intra-osseous needle and puts out a full paediatric cardiac arrest call. Elena is given two 20 ml/kg boluses of 0.9% saline, but does not respond. Two further 20 ml/kg boluses are given and the heart rate comes down to 170/min and she becomes warm to the ankles and wrists. However, the respiratory rate rises to 50/min and she requires 10 L/min of O2 to maintain a normal SaO2.
After discussion with the on-call paediatric and anaesthetic consultants, Elena is electively intubated and the local retrieval team is asked to transfer her to a PICU. Two further 20 ml/kg boluses are required to maintain perfusion before she leaves for PICU and broad spectrum antibiotics are started
On PICU Elena requires ventilation for three days. A catheter urine sample and the blood culture grow a coliform, and she is subsequently found to have a horseshoe kidney and vescico-ureteric reflux. She goes on to make a full recovery.
The PICU asks the local hospital to investigate why Elena deteriorated so markedly in hospital.
Expert opinion
Paediatric septicaemia results from the spread of microorganisms into the bloodstream, triggering a systemic inflammatory response syndrome (SIRS). It can be caused by many different organisms, but the end result is a picture of fever or hypothermia, with a tachycardia and tachyopnea.
Early signs of paediatric sepsis are often subtle, for example a mildly elevated heart rate, and any patient with an unexplained tachycardia needs to be monitored closely for signs of deterioration.
Hypothermia in sepsis is a well recognized finding and hypothermia in a child who has been previously febrile should not be ignored.
In this case the initial plan to admit for observation is valid, but in these cases, children must be observed regularly (e.g. 1 hourly observation). If a change in parameters is then found the child should be re-examined.
The ST2, Dr Edmunds, was also falsely reassured by the ‘normal’ inflammatory markers (often normal in early sepsis) and did not consider obtaining a catheter specimen urine or a suprapubic aspirate when Elena was still well. In fact, a low WCC can also be a sign of sepsis (this is thought to be related to a consumptive phenomenon).
The large volumes of fluid required by Elena to maintain perfusion are not unusual in paediatric sepsis related shock. The inevitable consequence of pulmonary oedema that follows large volume resuscitation should be anticipated and early elective intubation should always be considered.
Although Elena suffered no permanent harm, the care provided by the local hospital was substandard.
Legal comment
Luckily Elena suffered no permanent harm. The parents have made no formal complaint. However, there are clearly lessons to be learnt from the incident, to prevent the same errors being repeated. Neither the nurses, nor the ST2 were sufficiently aware of the potential significance of the hypothermia. Next time, the outcome may not be so fortunate.
There were individual failings in Elena’s treatment and the systems in place do not appear to be effective. As indicated in the General Points below, when a child is admitted for observation, the nursing staff should be told how often they are to be observed.
