Melendez Elliot, Bachur Richard
aDivision of Medicine Critical Care bDivision of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.
Curr Opin Pediatr. 2015 Jun;27(3):298-302. doi: 10.1097/MOP.0000000000000222.
Although there is abundant literature detailing the impact of quality improvement in adult sepsis, the pediatric literature is lacking. Despite consensus definitions for sepsis, which patients along the sepsis spectrum should receive aggressive management and the exact onset of sepsis ('time zero') are not clearly established. In the adult emergency department (ED), sepsis onset is defined as the time of entry into the ED; however, this definition cannot be applied to hospitalized patients or patients who evolve during their ED course. Since the time of sepsis onset will dictate the timeliness of subsequent process measures, the variable definitions in the literature make it difficult to generalize findings among prior studies.
Despite the variation in defining time zero, aggressive fluid administration, timely antibiotics, and compliance with sepsis bundles have been shown to improve mortality and to reduce hospital and intensive care length of stay. In addition, early identification tools show promise in beginning to define sepsis onset and retrospective search tools may allow improved case finding of those children of concern for sepsis.
Quality improvement in pediatric sepsis is evolving. As we continue to define quality measures, we must standardize the definition of sepsis onset. This definition should be applicable to any treatment venue to ensure measures can be evaluated across all settings. In addition, we must delineate which patients along the sepsis spectrum should be candidates for timely interventions and standardize other outcome measures beyond mortality.
尽管有大量文献详细阐述了成人脓毒症质量改进的影响，但儿科文献却很匮乏。尽管脓毒症有共识定义，但脓毒症谱系中的哪些患者应接受积极治疗以及脓毒症的确切发病时间（“零时间”）尚未明确确立。在成人急诊科（ED），脓毒症发病时间定义为进入ED的时间；然而，这个定义不适用于住院患者或在ED病程中病情进展的患者。由于脓毒症发病时间将决定后续治疗措施的及时性，文献中不同的定义使得在先前研究中概括研究结果变得困难。
尽管在定义零时间方面存在差异，但积极的液体输注、及时使用抗生素以及遵守脓毒症集束治疗已被证明可降低死亡率，并缩短住院时间和重症监护时间。此外，早期识别工具在开始定义脓毒症发病时间方面显示出前景，回顾性搜索工具可能有助于更好地发现那些疑似脓毒症的儿童病例。
儿科脓毒症的质量改进正在发展。在我们继续确定质量指标时，必须规范脓毒症发病时间的定义。这个定义应适用于任何治疗场所，以确保能在所有环境中评估治疗措施。此外，我们必须明确脓毒症谱系中的哪些患者应接受及时干预，并规范死亡率以外的其他结局指标。
